Category: Research and Studies

Prospective cohort study of water immersion in an Irish maternity setting

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Prospective cohort study of water immersion for labour and birth compared with standard care in an Irish maternity setting

Paula L Barry, Lean E McMahon, Ruth AM Banks, Ann M Fergus, Deirdre J Murphy

Abtract:

Objective To examine the birth outcomes for women and babies following water immersion for labour only, or for labour and birth.

Design Prospective cohort study.

Setting Maternity hospital, Ireland, 2016–2019.

Participants A cohort of 190 low-risk women who used water immersion; 100 gave birth in water and 90 laboured only in water. A control group of 190 low-risk women who received standard care.

Methods Logistic regression analyses examined associations between water immersion and birth outcomes adjusting for confounders. A validated Childbirth Experience Questionnaire was completed.

Main outcome measures Perineal tears, obstetric anal sphincter injuries (OASI), postpartum haemorrhage (PPH), neonatal unit admissions (NNU), breastfeeding and birth experiences.

Results Compared with standard care, women who chose water immersion had no significant difference in perineal tears (71.4% vs 71.4%, adj OR 0.83; 95% CI 0.49 to 1.39) or in OASI (3.3% vs 3.8%, adj OR 0.91; 0.26–2.97). Women who chose water immersion were more likely to have a PPH ≥500 mL (10.5% vs 3.7%, adj OR 2.60; 95% CI 1.03 to 6.57), and to exclusively breastfeed at discharge (71.1% vs 45.8%, adj OR 2.59; 95% CI 1.66 to 4.05). There was no significant difference in NNU admissions (3.7% vs 3.2%, adj OR 1.06; 95% CI 0.33 to 3.42). Women who gave birth in water were no more likely than women who used water for labour only to require perineal suturing (64% vs 80.5%, adj OR 0.63; 95% CI 0.30 to 1.33), to experience OASI (3.0% vs 3.7%, adj OR 1.41; 95% CI 0.23 to 8.79) or PPH (8.0% vs 13.3%, adj OR 0.73; 95% CI 0.26 to 2.09). Women using water immersion reported more positive memories than women receiving standard care (p<0.01).

Conclusions Women choosing water immersion for labour or birth were no more likely to experience adverse birth outcomes than women receiving standard care and rated their birth experiences more highly.

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Waterbirth: a national retrospective cohort study… 2021

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

H. Aughey,J. Jardine,N. Moitt,K. Fearon,J. Hawdon,D. Pasupathy,I. Urganci,NMPA Project Team &T. Harris

BMC Pregnancy and Childbirth volume 21, Article number: 256 (2021)

Abstract

Background

Waterbirth is widely available in English maternity settings for women who are not at increased risk of complications during labour. Immersion in water during labour is associated with a number of maternal benefits. However for birth in water the situation is less clear, with conclusive evidence on safety lacking and little known about the characteristics of women who give birth in water.

This retrospective cohort study uses electronic data routinely collected in the course of maternity care in England in 2015–16 to describe the proportion of births recorded as having occurred in water, the characteristics of women who experienced waterbirth and the odds of key maternal and neonatal complications associated with giving birth in water.

Methods

Data were obtained from three population level electronic datasets linked together for the purposes of a national audit of maternity care. The study cohort included women who had no risk factors requiring them to give birth in an obstetric unit according to national guidelines. Multivariate logistic regression models were used to examine maternal (postpartum haemorrhage of 1500mls or more, obstetric anal sphincter injury (OASI)) and neonatal (Apgar score less than 7, neonatal unit admission) outcomes associated with waterbirth.

Results

46,088 low and intermediate risk singleton term spontaneous vaginal births in 35 NHS Trusts in England were included in the analysis cohort. Of these 6264 (13.6%) were recorded as having occurred in water. Waterbirth was more likely in older women up to the age of 40 (adjusted odds ratio (adjOR) for age group 35–39 1.27, 95% confidence interval (1.15,1.41)) and less common in women under 25 (adjOR 18–24 0.76 (0.70, 0.82)), those of higher parity (parity ≥3 adjOR 0.56 (0.47,0.66)) or who were obese (BMI 30–34.9 adjOR 0.77 (0.70,0.85)). Waterbirth was also less likely in black (adjOR 0.42 (0.36, 0.51)) and Asian (adjOR 0.26 (0.23,0.30)) women and in those from areas of increased socioeconomic deprivation (most affluent versus least affluent areas adjOR 0.47 (0.43, 0.52)).

There was no association between delivery in water and low Apgar score (adjOR 0.95 (0.66,1.36)) or incidence of OASI (adjOR 1.00 (0.86,1.16)). There was an association between waterbirth and reduced incidence of postpartum haemorrhage (adjOR 0.68 (0.51,0.90)) and neonatal unit admission (adjOR 0.65 (0.53,0.78)).

Conclusions

In this large observational cohort study, there was no association between waterbirth and specific adverse outcomes for either the mother or the baby. There was evidence that white women from higher socioeconomic backgrounds were more likely to be recorded as giving birth in water. Maternity services should focus on ensuring equitable access to waterbirth.

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

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Background: For women at low risk of childbirth complications, water immersion during labour is a care option in many high income countries.

Our aims were (a) to describe maternal characteristics, intrapartum events, interventions, maternal and neonatal outcomes for all women who used a birthing pool during labour who either had a waterbirth or left the pool and had a landbirth, and for the subgroup of women who had a waterbirth in 19 obstetric units, and (b) to compare maternal characteristics, intrapartum events, interventions, and maternal and neonatal outcomes for women who used a birthing pool with a control group of women who did not use a birthing pool for whom we prospectively collected data in a single centre.

Methods: Prospective observational study in 19 Italian obstetric units 2002-2005.

Participants were: (a) 2,505 women in labour using a birthing pool in 19 obstetric units; and (b) 114 women in labour using a birthing pool and 459 women who did not use a birthing pool in one obstetric unit.

Descriptive statistics were calculated for the sample as a whole and, separately, for those women who gave birth in water. Categorical data were compared using Chi square statistics and continuous data by T-tests.

Results: Overall, 95.6% of women using a birthing pool had a spontaneous vertex delivery, 63.9% of which occurred in water. Half of nulliparas and three quarters of multiparas delivered in water.

Adverse maternal and neonatal outcomes were rare.

There were two cases of umbilical cord snap with waterbirth.

Compared with controls, significantly more women who used a birthing pool adopted an upright birth position, had hands off delivery technique, and a physiological third stage.

Significantly fewer nulliparas had an episiotomy, and more had a second degree perineal tear, with no evidence of a difference for extensive perineal tears.

Conclusions: Birthing pool use was associated with spontaneous vaginal birth.

The increase in second degree tears was balanced by fewer episiotomies.

Undue umbilical cord traction should be avoided during waterbirth.

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

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Background: Water immersion during labour can provide benefits including reduced need for regional analgesia and a shorter labour.

However, in the United Kingdom a minority of women use a pool for labour or birth, with pool use particularly uncommon in obstetric-led settings.

Maternity unit culture has been identified as an important influence on pool use, but this and other possible factors have not been explored in-depth.

Therefore, the aim of this study was to identify factors influencing pool use through qualitative case studies of three obstetric units and three midwifery units in the UK.

Methods: Case study units with a range of waterbirth rates and representing geographically diverse locations were selected. Data collection methods comprised semi-structured interviews, collation of service documentation and public-facing information, and observations of the unit environment.

There were 111 interview participants, purposively sampled to include midwives, postnatal women, obstetricians, neonatologists, midwifery support workers and doulas.

A framework approach was used to analyse all case study data.

Results: Obstetric unit culture was a key factor restricting pool use.

We found substantial differences between obstetric and midwifery units in terms of equipment and resources, staff attitudes and confidence, senior staff support and women’s awareness of water immersion.

Generic factors influencing use of pools across all units included limited access to waterbirth training, sociodemographic differences in desire for pool use and issues using waterproof fetal monitoring equipment.

Conclusions: Case study findings provide new insights into the influence of maternity unit culture on waterbirth rates.

Access to pool use could be improved through midwives based in obstetric units having more experience of waterbirth, providing obstetricians and neonatologists with information on the practicalities of pool use and improving accessibility of antenatal information.

In terms of resources, recommendations include increasing pool provision, ensuring birth room allocation

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

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Background: There is limited research examining midwives’ education, knowledge and practice around immersion in water for labour or birth. Our aim was to address this gap in evidence and build knowledge around this important topic.

Methods: This mixed method study was performed in two phases, between August and December 2016, in the birth centre of a tertiary public maternity hospital in Western Australia.

Phase one utilised a cross sectional design to examine perceptions of education, knowledge and practice around immersion in water for labour or birth through a questionnaire.

Phase two employed a qualitative descriptive design and focus groups to explore what midwives enjoyed about caring for women who labour or birth in water and the challenges midwives experienced with waterbirth.

Frequency distributions were employed for quantitative data. Thematic analysis was undertaken to extract common themes from focus group transcripts.

Results: The majority (85%; 29 of 34) of midwives surveyed returned a questionnaire.

Results from phase one confirmed that following training, 93% (27 of 29) of midwives felt equipped to facilitate waterbirth and the mean waterbirths required to facilitate confidence was seven.

Midwives were confident caring for women in water during the first, second and third stage of labour and enjoyed facilitating water immersion for labour and birth.

Finally, responses to labour and birth scenarios indicated midwives were practicing according to state-wide clinical guidance.

Phase two included two focus groups of seven and five midwives.

Exploration of what midwives enjoyed about caring for women who used water immersion revealed three themes: instinctive birthing; woman-centred atmosphere; and undisturbed space.

Exploration of the challenges experienced with waterbirth revealed two themes: learning through reflection and facilities required to support waterbirth.

Conclusions: This research contributes to the growing knowledge base examining midwives’ education, knowledge and practice around immersion in water for labour or birth.

It also highlights the importance of exploring what immersion in water for labour and birth offers midwives, as this research suggests they are integral to sustaining waterbirth as an option for low risk women.

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

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Background: There is a gap in knowledge and understanding relating to the experiences of women exposed to the opportunity of waterbirth.

Our aim was to explore the perceptions and experiences of women who achieved or did not achieve their planned waterbirth.

Methods: An exploratory design using critical incident techniques was conducted between December 2015 and July 2016, in the birth centre of the tertiary public maternity hospital in Western Australia. Women were telephoned 6 weeks post birth.

Demographic data included: age; education; parity; and previous birth mode.

Women were also asked the following: what made you choose to plan a waterbirth?; what do you think contributed to you having (or not having) a waterbirth?; and which three words would you use to describe your birth experience?

Frequency distributions and univariate comparisons were employed for quantitative data.

Thematic analysis was undertaken to extract common themes from the interviews.

Results: A total of 31% (93 of 296) of women achieved a waterbirth and 69% (203 of 296) did not. Multiparous women were more likely to achieve a waterbirth (57% vs 32%; p < 0.001).

Women who achieved a waterbirth were less likely to have planned a waterbirth for pain relief (38% vs 52%; p = 0.24).

The primary reasons women gave for planning a waterbirth were: pain relief; they liked the idea; it was associated with a natural birth; it provided a relaxing environment; and it was recommended.

Two fifths (40%) of women who achieved a waterbirth suggested support was the primary reason they achieved their waterbirth, with the midwife named as the primary support person by 34 of 37 women.

Most (66%) women who did not achieve a waterbirth perceived this was because they experienced an obstetric complication.

The words women used to describe their birth were coded as: affirming; distressing; enduring; natural; quick; empowering; and long.

Conclusions: Immersion in water for birth facilitates a shift of focus from high risk obstetric-led care to low risk midwifery-led care.

It also facilitates evidence based, respectful midwifery care which in turn optimises the potential for women to view their birthing experience through a positive lens.

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

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Aims: To gather, quality assess, synthesize and interpret the views, feeling, and experiences of women who used water immersion during labour and/or birth.

Design: A systematic meta-thematic synthesis and GRADE-CERQual.

Data sources: We searched MEDLINE, CINHAL, PsychINFO, AMED, EMBASE (MIDIRS only), LILACS, AJOL. Additional searches were carried out using Ethos (thesis database), cross-referencing against Google Scholar and citation chasing. Searches were carried out in August 2019, updated February 2020.

Methods: Studies that met the selection criteria were appraised for quality. Data were extracted from the studies using meta-thematic analytical techniques; coding, descriptive findings, and analytical findings. The descriptive findings were subjected to confidence assessments using GRADE-CERQual.

Results: Seven studies met the inclusion criteria. Nine key statements of findings were generated – one had high confidence, three moderate, three low and one very low confidence in the findings. The analytical findings generated three main themes: Liberation and Self-Emancipation, Synergy, transcendence and demarcation and Transformative birth and beyond. Overall, women experienced warm water immersion during labour and/or birth positively. Both the water and pool itself, facilitated women’s physical and psychological needs during labour and/or birth, including offering effective analgesia. Our findings indicated that birthing pools are versatile tools that provide for a space that women can adapt and influence to best suit their individual needs.

Conclusion: Women who used warm water immersion for labour and/or birth describe liberating and transformative experiences of welcoming their babies into the world. They were empowered, liberated, and satisfied. We recommend maternity professionals and services offer water immersion as a standard method of pain relief during labour/birth.

Impact: Understanding women’s experiences of labour and birth will inform future clinical practice. Midwives are optimally positioned to enhance women’s access to water immersion. These findings have implications for education, guideline, and policy development as well as clinical practice.

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

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Water birth is widely available in English maternity settings for women who are not at increased risk of complications during labour. Immersion in water during labour is associated with a number of maternal benefits.

However for birth in water the situation is less clear, with conclusive evidence on safety lacking and little known about the characteristics of women who give birth in water.

This retrospective cohort study uses electronic data routinely collected in the course of maternity care in England in 2015–16 to describe the proportion of births recorded as having occurred in water, the characteristics of women who experienced water birth and the odds of key maternal and neonatal complications associated with giving birth in water.

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

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Abstract

Aims: To explore retrospective descriptions about benefits, negative experiences and preparatory information related to waterbirths.

Design: A qualitative study.

Methods: Women who gave birth in water with healthy pregnancies and low-risk births were consecutively recruited between December 2015–October 2018 from two birthing units in Sweden.

All who gave birth in water during the recruitment period were included (N = 155) and 111 responded to the survey.

Women were emailed a web-based survey six weeks postpartum. Open-ended questions were analysed with qualitative content analysis.

Results: Two themes were identified related to benefits: (a) physical benefits: the water eases labour progression while offering buoyancy and pain relief; and (b) psychological benefits: improved relaxation and control in a demedicalized and safe setting.

Two themes were identified related to negative experiences: (a) equipment related issues due to the construction of the tub and issues related to being immersed in water; and (b) fears and worries related to waterbirth.

In regard to preparatory information, respondents reported a lack of general and specific information related to waterbirths, even after they contacted birthing units to ask questions.

Supplemental web-based information was sought, but the trustworthiness of these sources was questioned and a need for trustworthy web-based information was articulated.

Conclusion: Women who give birth in water experience physical and psychological benefits, but need better equipment and sufficient information.

There is room for improvement with regard to prenatal and intrapartum care of women who give birth in water.

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Water birth in Sweden – a comparative study

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The literature describes advantages for mothers giving birth in water, but waterbirth is controversial in Sweden and has not been offered at hospitals until recently.

This study aimed to describe and compare the characteristics and outcome of waterbirths with those of spontaneous vaginal births at the same clinics. Material and methods.

A retrospective cohort study was conducted on all waterbirths at two maternity units in Sweden from March 2014 to November 2015 (n = 306), and a consecutively selected comparison group of 306 women having conventional spontaneous vaginal births.

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An economic evaluation of water birth

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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.

Water contamination and the rate of infections for water births

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A. Thoeni*, F. Ploner and N. Zech 2008

Department of Gynaecology and Obstetrics, District Hospital of Vipiteno, Northern-Italy 

Abstract:

Objective: The potential for increased risks of infection is an important concern with water births.

We performed microbiological analyses on water samples taken from birthing pools before and after water births, and compared the rate of neonatal infection arising after water births with that arising after conventional delivery.

Materials and Methods:

In this prospective observational study beginning in 2001, water from the delivery pool was analyzed to determine the prevailing microorganisms.

Two water samples were taken at each delivery.

The first sample (sample A) was taken after the tub was filled with tap water; the second sample (sample B) was taken after the delivery.

The high rate of water contamination with Legionella pneumophila and Pseudomonas aeruginosa led us to install a filter system (Aquasafe –FilterR) into the supply hose for the birthing pool to reduce the water contamination.

This intervention significantly reduced the total microbial loading and there was no longer evidence of Legionella pneumophila.

Furthermore, we determined the rate of neonatal infections in infants delivered in water and compared it with those delivered conventionally out of the water.

Results:

Samples were obtained from 300 out of a total of 1,625 water deliveries, which took place between 2001 and 2007. Before the installation of a filter system, 29% of the A-samples showed bacterial growth with Legionella pneumophila,
22% with Pseudomonas aeruginosa, 18% with enterococci, 32% with coliforms, and 8% with Escherichia coli.

After the installation of the filter system, the water contamination decreased considerably:
– there were no further signs of Legionella bacteria, and Pseudomonas aeruginosa was found in only 3% and coliforms in 13% of the samples, respectively.

By comparing the microbiological composition of the B-samples before and after installation of the filter system, we concluded that the intervention did not influence the microbial loading of the water, which occurred during and as a result of
the whole delivery phase.

The microbiological loading of the water in the birthing pool after it was filled may have partly originated from the insufficient cleaning and disinfections of the birthing pool and after changing the cleaning records there was no longer any evidence of a significant microbial count (unpublished data).

Of the B-samples, 82% contained large amounts of coliforms, 64% contained Escherichia coli with concentrations of up to 105 CFU/100 mL, and 8-12% contained Pseudomonas aeruginosa.

Staphylococcus aureus and Candida spp were also
present in moderate amounts.

The rate of neonates treated with antibiotics for suspected infection on the basis of clinical symptoms (tachypnoea, skin color) or laboratory findings (CRP rise, leukocytosis) was 1.05% after water births (17 out of 1,625) compared with
1.75% (20 out of 1,139) after conventional delivery (p<0.05).

Conclusion:

Based on our results and the literature, water birth is a valuable alternative to traditional delivery when certain criteria are met and risk factors are excluded.

During water birth, faeces are discharged into the pool and the water is
contaminated with a variety of microorganisms.

However, contamination of the water with such microorganisms seems not to translate into an increased risk of neonatal infection.

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Underwater birth and neonatal respiratory distress

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Zainab Kassim, clinical research fellow in neonatology1, Maria Sellars, consultant in radiology2, Anne Greenough, professor of neonatology and clinical respiratory physiology1 

1 Department of Child Health, Guy’s, King’s and St Thomas’ School of Medicine, King’s College Hospital, London SE5 9RS, 2 Department of Radiology, King’s College Hospital, London

Introduction

In 1992 the House of Commons Select Health Committee’s report on maternity services recommended that all hospitals should provide women with the “option of a birthing pool where this is practicable.

“1 A subsequent surveillance study of all NHS maternity units between 1994 and 1996 found that 0.6% of all deliveries in England and Wales occurred in water.2

Rawal and colleagues have suggested that water births have become popular among mothers and midwives because the buoyancy and warmth of the water promotes natural labour while providing a non-invasive safe and effective form of pain management.3

Practitioners and parents should remember, however, that birthing pools pose potential risks for the baby. We report on a newborn baby who developed respiratory distress due to aspiration after an underwater birth.

Case Report

A full term male infant weighing 3150 g was born in the birthing pool of the labour ward of our hospital. His mother was a 34 year old, healthy primigravida who had had an uneventful pregnancy.

She had gone into spontaneous labour at 40 weeks’ gestation and had had no maternal fever during labour; at delivery the membranes had been ruptured for less than 18 hours. The baby was born underwater.

He required no resuscitation but, when reviewed at one hour, was grunting. As the grunting persisted, he was admitted to the neonatal intensive care unit at 3 hours of age. He had no fever but was tachypnoeic and had intercostal recession and nasal flaring.

He needed supplementary oxygen to maintain his oxygen saturation level at 92%; his need for supplementary oxygen persisted for nine hours. He was screened for infection and started on antibiotics (benzylpenicillin and gentamicin).

In view of his respiratory distress, which persisted for 48 hours, he was designated “nil by mouth” and fluid was administered intravenously until he had recovered. Chest radiography soon after admission showed widespread changes consistent with aspiration of the birthing pool water (figure).

Further radiography, on day 3, showed resolution of the abnormalities, and the infection screen was negative. The infant made a full recovery and, when seen as an outpatient at age 3 months, was free of symptoms.

Discussion

Some researchers have suggested that “babies can only drown when submerged, only if they are already severely compromised and literally at their `last gasp,’ as water simulates vagal inspiration receptors causing glottic closure.”4

In lambs, however, inhibitory mechanisms that prevent breathing until the lamb is in contact with cold air can be overridden by sustained hypoxia.5

Likewise, in a birthing pool, some babies with unrecognised hypoxia may gasp underwater. Indeed, the 1994 to 1996 survey cited two reports of water aspiration,2 and similar cases have been documented in the literature.6-8

Our case report emphasises the adverse effects of aspiration of water in birthing pools. Although such events seem uncommon, this may be the result of under-reporting.

Respiratory distress immediately after birth is common and has various aetiologies. Thus, unless a careful history is taken, the cause the respiratory distress may be misdiagnosed.9

We are confident that the case we report was due to aspiration of water as the infant developed symptoms soon after birth, with resolution by 48 hours.

In addition, there were no risk factors for infection or indeed any bacterial infection identified. Infection after water birth has been described.10-12

The baby in our case report was delivered after spontaneous labour at term, making transient tachypnoea of the newborn unlikely; indeed, the chest radiograph was consistent not with that diagnosis but with aspiration.

A systemic review of randomised trials has shown that immersion during labour is associated with significant reductions in the use of epidural, spinal, or paracervical analgesia and in women’s reports of pain, but highlighted there were insufficient data to determine the outcome from randomised trials of birth in water for women or their infants.13

In addition to water aspiration and subsequent pulmonary oedema,8 however, other adverse neonatal outcomes after water birth have been reported; these include water intoxication, hyponatraemia, hypoxic ischaemic encephalopathy, cord rupture with neonatal haemorrhage, and pneumonia.12 14

Women who have water births are usually considered to be “low risk,” and so they and their infants should have an excellent prognosis. Our case report and review of the literature confirm that water birth has risks for the newborn.

Practitioners and parents need to be aware of these potential risks so that mothers can make a fully informed decision about place of delivery.

Water birth can be associated with adverse effects in the newborn

Contributors: ZKand AG collected the clinical data, and MS col- lected the radiographic data. All authors contributed to writing the paper, and AG is the guarantor.

Funding: No special funding. Competing interests: None declared.

References

      1. House of Commons Health Select Committee. Maternity services. Second report. London: HMSO, 1992.
      2. Ruth E, Gilbert P, Tookey A. Prenatal mortality and morbidity among babies delivered in water: surveillance study and postal survey. BMJ 1999;319: 483- 7.
      3. Rawal J, Shah A, Stirk F, Mehtar S. Water birth and infection in babies. BMJ 1994;309: 511-2.
      4. Kitzinger S. Sheila Kitzinger’s letter from Europe: the waterbirth debate up-to- date. Birth 2000;27: 214-6.
      5. Johnson P. To breathe or not to breathe. Br J Obstet Gynaecol 1996; 103: 202- 3.
      6. Rosser J. Is water birth safe? The facts behind the controversy. MIDIRS Midwifery Digest 1994;4: 4-6.
      7. Barry CN. Water births. Could saline in the pool reduce the potential hazards? BMJ 1995;310: 1602.
      8. Nguyen S, Kuschel C, Teele R, Spooner C. Water birth—a near-drowning experience. Pediatrics 2002;110: 411-3.
      9. Bowden K, Kessler D, Pinette M, Wilson E. Underwater birth: missing the evidence or missing the point? Pediatrics 2003;112: 972-3.
      10. Rawal J, Shah A, Stirk F, Mehtar S. Water birth and infection in babies. BMJ 1994;309: 511.
      11. Nagai T, Sobajima H, Iwasa M, Tsuzuki T, Kura F, Amemura-Maekawa J, et al. Neonatal sudden death due to Legionella pneumonia associated with water birth in a domestic spa bath. J Clin Microbiol 2003:41: 2227-9.
      12. Pinette MG, Wax J, Wilson E. The risks of underwater birth. Am J Obstet Gynecol 2004;190: 1211-5.
      13. Cluett ER, Nikodem VC, McCandilish RE, Burns EE. Immersion in water in pregnancy, labour and birth. Cochrane Database Syst Rev 2005;(1)
      14. Schroeter K. Water births: a naked emperor. Pediatrics 2004;114: 855-8.

(Accepted 16 March 2005)

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The use of water in labour and birth – NZ College of Midwives

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The New Zealand College of Midwives (Inc) supports immersion of women in warm water during labour as a method of pain management.

There is no evidence that remaining in water for the birth of the baby leads to adverse outcomes for the mother or baby where the labour has been within normal parameters.

Definition:

Water birth means where a baby is born fully submerged into water.

Rationale:

• Evidence supports immersion in warm water as an effective form of pain relief that reduces the use of narcotics.

• There is no evidence to suggest that immersion in water during labour or birth in water leads to any detrimental effects for either the mother or her baby.

• Evidence that immersion in water during labour reduces the length of active labour is inconclusive.

• Evidence that birth in water reduces perineal trauma or blood loss is inconclusive.

Guidelines:

Midwives offering water immersion for labour and for birth are responsible for ensuring the information given to women is accurate and up to date.

The following guidelines are recommended:

• There are no adverse factors noted in foetal or maternal wellbeing during labour.

• Baseline assessments of both maternal and baby wellbeing should be done prior to entering the bath/pool and assessments continued throughout the time in water as for any normal labour.

• Vaginal examinations can be performed with the woman in water.

• Pethidine should not be given to women labouring in water.

• The water temperature should be kept as cool as the woman finds comfortable during the first stage of labour (around 35oC) and increased to no more than 37oC for the baby’s birth.

• If maternal temperature rises more than 1oC above the baseline temperature then the water should be cooled or the woman encouraged to leave the bath/pool. Women need to be aware of this in advance.

• Water temperature should be recorded as the woman enters the bath/pool and regularly during the time she remains in the pool.

• Careful documentation should be kept of maternal and water temperatures, FHR and the approximate surface area of the woman’s body submerged.

• The cord should not be clamped and cut until after the birth of the baby’s body.

• The baby should be brought to the surface immediately, with the head facing down to assist the drainage of water from the baby’s mouth and nose.

• The baby’s body can remain in the water to maintain warmth, unless the baby’s condition dictates otherwise. (Note: babies born in water may take slightly longer to establish respirations than those born into air. Maintain close observation of colour, heart rate and respirations.)

• Third stage should be managed physiologically as for any other low risk birth. If oxytocin is required or third stage is prolonged the woman is assisted to leave the bath/pool.

• Midwives must ensure that baths and pipes are thoroughly cleaned after use.

References:

Title: Labour and delivery in the birthing pool
Author: Forde, C, Creighton, S, Batty, A, Howden, J, Summers-Ma, S, and Ridgeway, G

Title: Warm tub bathing during labour: maternal and neonatal effects
Authors: Ohlsson, G, Buchave, P, Leandersson, U, Nordstrom, L, Rydhstrom, H, and Sjolin, I
Source: Acta Obstetricia et Gynecologica Scandinavica, Vol 80, pp 311 – 314, 2001

Title: Immersion in water in the first stage of labour: a randomised controlled trial
Authors: Eckert, K, Turnbull, D, and MacLennan, A
Source: Birth, Volume 28, No 2, pp 84–93, June 2001

Title: Immersion in water during first stage of labour
Author: Homer, C
Source: Letter to the editor, Birth, Vol. 29, No 1, March, 2002

Title: Waterbirths: a comparative study. A prospective study on more than 2000 waterbirths Authors: Geissbuhler, V and Eberhard, J
Source: Foetal Diagnosis Therapy, Vol. 15, pp. 291 – 300, 2000
Title: Immersion in water in pregnancy, labour and birth Author: Nikodem, VC
Source: Cochrane Database Systematic Review, 2000

Title: Perinatal mortality and morbidity among babies delivered in water: surveillance study and postal survey
Authors: Gilbert, R and Tookey, P
Source: British Medical Journal, 319 (7208), pp. 483 – 487, 1999

Title: Birth under water – to breathe or not to breath
Author: Johnson, P
Source: British Journal of Obstetrics and Gynaecology, 103, 202-208, 1996

Title: Labour and birth in water: temperature of pool is important
Authors: Deans, AC and Steer, PJ
Source: British Medical Journal. 311:390-391, 1995

Title: Waterbirth – An attitude to care
Author: Garland, D
Source: Books for Midwives, 1995. Chesire

Title: Foetal hypothermia risk from warm water immersion
Author: Charles, C
Source: British Journal of Midwifery

The purpose of New Zealand College of Midwives Consensus Statements is to provide women, midwives and the maternity services with the profession’s position on any given situation.

The guidelines are designed to educate and support best practice.

All position statements are regularly reviewed and updated in line with evidence-based practice.

Water birth, more than a trendy alternative: a prospective, observational study

Posted on by K.D.Brainin

Zanetti-Dällenbach, Rosanna1; Lapaire, Olav; Maertens, Anne; Holzgreve, Wolfgang; Hösli, Irene (2006) Archives of Gynecology and Obstetrics, Volume 274, Number 6, October 2006 , pp. 355-365(11)

Abstract:

To prospectively assess the effect of water birth on maternal and fetal outcomes in a selected low-risk collective of a tertiary obstetrical unit.

In this prospective observational study, 513 patients of a low-risk collective, who requested a water birth, were studied during the years 1998-2002. Primary outcome measurements included the maternal and fetal parameters.

Secondary outcome measurements comprised data on the incidence of water births in an interested, low- risk population in an academic hospital.

All groups were similar in terms of demographic and obstetric data. Significant differences were observed in maternal outcome parameters, which included the use of analgesia/anesthesia during labor, the duration of first and second stages of labor, perineal tears and episiotomy rate.

No differences were seen in all observed fetal outcome parameters including APGAR scores, arterial and venous pH, admission rate to neonatal intensive care unit and infection rate.

Water birth is a valuable and promising alternative to traditional delivery methods. The maternal and fetal outcomes were similar to traditional land births. However, currently there still exist some deficits in the scientific evaluation of its safety.

Therefore, the selection of a low-risk collective is essential to minimize the risks with the addition of strictly maintained guidelines and continuous intrapartum observation and fetal monitoring.

Based on our results and the literature, water births are justifiable when certain criteria are met and risk factors are excluded.

 

Shoulder dystocia at water birth

Posted on by K.D.Brainin

Nadine Massiah MBBS

Obstetrics and Gynaecology Department
Furness General Hospital
Barrow in Furness UK

Vincent Bamigboye MRCOG
Obstetrics and Gynaecology Department
Furness General Hospital
Barrow in Furness UK

Citation: N. Massiah & V. Bamigboye : Shoulder dystocia at water birth . The Internet Journal of Gynecology and Obstetrics. 2008 Volume 9 Number 1

Abstract

Health professionals providing obstetric care should be familiar with guidelines for shoulder dystocia. Regular drills are fundamental to the improvement of team work, enhancing communication skills and essential for good outcomes5.

Obstetric birthing simulators should be considered since they significantly improve competence in the management of shoulder dystocia6,7.

Learning and teaching are continuous processes in our practice. Optimal training is required to minimize morbidity and mortality of this obstetric complication.

Case Report

A 33 year old, para 1 lady presented in active labour at 40 weeks gestation. The abdominal findings were fundal height 39 cm, longitudinal lie and cephalic presentation.

Vaginal examination revealed cervical dilatation of 5 cm, occipito-anterior position of the foetal head at station minus two. The membranes were intact.

The booking investigations, dating and anomaly scans were found to be normal. The current pregnancy was uncomplicated. The first pregnancy and vaginal delivery were uneventful.

The pool was requested for labour and delivery. The labour progressed well to full dilatation. There was good descent of the head with active pushing. After delivery of the head, the shoulders were impacted. Mc Robert’s manoeuvre and suprapubic pressure were attempted without success.

The patient was moved from the birthing pool to the bed. Mc Robert’s manoeuvre, suprapubic pressure and downward traction of the head led to delivery of the anterior shoulder followed by the remainder of the body.

The time interval between the delivery of head and body was 3 minutes. The estimated blood loss was 350 mls. The neonate had a birth weight of 4200g with an Apgar score of 8, 9 and 10. Paediatric examination of the neonate was normal.

Discussion

The incidence of shoulder dystocia at water birth is 0.16%1. This case highlights that it is vital to be prepared for emergencies even with low risk women. They may occur in unfamiliar situations. Since the patient was wet, her safety whilst being moved to the bed was of great concern.

This was done carefully but quickly. It is estimated that the umbilical cord pH falls by 0.04 unit/min after delivery of the head2. A delay in delivery of the shoulders may result in cerebral hypoxia, cerebral palsy or death.

Forty seven percent of deaths from shoulder dystocia were within 5 minutes of delivery of the head3. The principles of management were widening of the pelvic diameters and repositioning the foetal shoulders into the oblique pelvic diameter to facilitate delivery4.

Health professionals providing obstetric care should be familiar with guidelines for shoulder dystocia.

Regular drills are fundamental to the improvement of team work, enhancing communication skills and essential for good outcomes5.

Obstetric birthing simulators should be considered since they significantly improve competence in the management of shoulder dystocia6,7.

Learning and teaching are continuous processes in our practice. Optimal training is required to minimize morbidity and mortality of this obstetric complication.

References

1. Thöni A, Zech N, Ploner F. Giving birth in the water: experience after 1,825 water deliveries. Retrospective descriptive comparison of water birth and traditional delivery methods. Gynäkologisch-geburtshilfliche Rundschau 2007; 47(2):76-80.

2. Wood C, Ng KH, Hounslow D, Benning H. Time – an important variable in normal delivery. Journal of obstetrics and gynaecology of the British Commonwealth 1973; 80(4):295-300.

3. Confidential Enquiries into Stillbirths and Deaths in Infancy. Fifth Annual Report. London: Maternal and Child Health Research Consortium, 1998. (s)

4. Draycott TJ, Fox R, Montague IA. Shoulder dystocia. RCOG Guideline No. 42. London:RCOG 2005.

5. Sorensen SS. Emergency drills in obstetrics: reducing risk of perinatal death or permanent injury. JONAS Healthcare Law Ethics and Regulation 2007; 9(1):9-16.

6. Deering S, Poggi S, Macedonia C, Gherman R, Satin AJ. Improving resident competency in the management of shoulder dystocia with simulation training. Obstetrics and Gynecology 2004;103(6):1224-8

7. Crofts JF, Bartlett C, Ellis D, Hunt LP, Fox R, Draycott TJ. Training for shoulder dystocia: a trial of simulation using low-fidelity and high-fidelity mannequins. Obstetrics and Gynecology 2006; 108(6):1477-85.

The use of water during childbirth – MIDIRS

Posted on by K.D.Brainin

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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  4. Rush J, Burlock S, Lambert K et al.The effects of whirlpool baths in labor: a randomized, controlled trial. Birth 1996;23:136-43.
  5. House of Commons (1991-92). Health Committee. Second report. Maternity services. HC 29-I. London, HMSO, 1992.
  6. Alderdice F, Renfrew M, Marchant S et al. Labour and bir th in water in England and Wales, BMJ 1995;310:837.
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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.
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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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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.
  24. ErikssonM,MattssonLA,LadforsL.Earlyorlatebathduringthefirststageoflabour:arandomised study of 200 women. Midwifery 1997;13:146-8.
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  60. Brown L.The tide has turned: audit of water birth. Br J Midwifery 1998;6:236-43.
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  62. Burns E.Waterbirth. MIDIRS Midwifery Dig 2001;11(suppl 2):S10-3.
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  63. Nguyen S, Kuschel C,Teele R et al.Water birth – a near-drowning experience. Pediatrics 2002;110:411-3.
  64. RobinsonJ.AwaterbirthdeathinSweden.AIMSJ1993;5:7-8.
  65. GarlandD,JonesK.Waterbirth:updatingtheevidence.BrJMidwifery1997;5:368-73.
  66. BeakeS.Waterbirth:aliteraturereview.MIDIRSMidwiferyDig1999;9:473-7.
  67. Grunebaum A, Chervenak F.The baby or the bathwater: which should be discarded? Perinat Med 2004;32(4):306-7.
  68. JenkinsR.Assessingtheeffectofanewhealthtechnology.In:BeechBALed.Waterbirthunplugged. Hale: Books for Midwives Press, 1996:53-8.

 

 

 

Characteristics, interventions, and outcomes of women who used a birthing pool

Posted on by K.D.Brainin

Ethel E. Burns, RM, MSc, Mary G. Boulton, PhD, Elizabeth Cluett, RM, PhD,
Victoria R. Cornelius, PhD, and Lesley A. Smith, PhD 2012

Background: Birthing pools are integrated into maternity care in the United
Kingdom and are a popular care option for women in midwifery-led units and at home.

The objective of this study was to describe and compare maternal characteristics, intrapartum events, interventions, and maternal and neonatal outcomes by planned place of birth for women who used a birthing pool.

Methods:

A total of 8,924 women at low risk of childbirth complications were recruited from care settings in England, Scotland, and Northern Ireland.

Descriptive analysis was performed. Results: Overall, 7,915 (88.9%) women had a
spontaneous birth (5,192, 58.3% water births), of whom 4,953 (55.5%) were nulliparas.

Fewer nulliparas whose planned place of birth was the community (freestanding midwifery unit or home) had labor augmentation by artificial membrane rupture (149, 11.3% [95% CI:9.6–13.1]), compared with an alongside midwifery unit (271, 22.7% [95% CI: 20.3–25.2]), or obstetric unit (639, 26.3% [95% CI: 24.5–28.1]). Results were similar for epidural analgesia and episiotomy.

More community nulliparas had spontaneous birth (1,172, 88.9% [95% CI: 87.1–90.6]), compared with birth in an alongside midwifery unit (942, 79% [95% CI: 76.6–81.3]) and obstetric unit (1,923, 79.2% [95% CI: 77.5–80.8]); and fewer required hospital transfer (265, 20% [95% CI: 17–22.2]) compared with those in an alongside midwifery unit (370, 31% [95% CI: 28.3–33.7]).

Results for multiparas and newborns were similar across care settings. Twenty babies had an umbilical cord snap, 18 (90%) of which occurred during water birth. Conclusions: Birthing pool use was associated with a high frequency of spontaneous birth, particularly among nulliparas.

Findings revealed differences in midwifery practice between obstetric units, alongside midwifery units, and the community, which may affect outcomes, particularly for nulliparas.

No evidence was found for a difference across care settings in interventions or outcomes in multiparas or in outcomes for newborns.

During water birth, it is important to prevent undue traction on the cord as the baby is guided to the surface. (BIRTH 39:3 September 2012)

The article contains useful studies of water births in the UK by the NHS.

Please click here to read the full article

 

 

 

Cochrane Review – Immersion in water

Posted on by K.D.Brainin

Background

Enthusiasts suggest that labouring in water and waterbirth increase maternal relaxation, reduce analgesia requirements and promote a midwifery model of care. Sceptics cite the possibility of neonatal water inhalation and maternal/neonatal infection.

Objectives

To assess the evidence from randomised controlled trials about immersion in water during labour and waterbirth on maternal, fetal, neonatal and caregiver outcomes.
Search strategy

We searched the Cochrane Pregnancy and Childbirth Group’s Trials Register (October 2008).

Selection criteria

Randomised controlled trials comparing any bath tub/pool with no immersion during labour and/or birth.

Data collection and analysis

We assessed trial eligibility and quality and extracted data independently. One review author entered data and another checked for accuracy.

Main results

This review includes 11 trials (3146 women); eight related to the first stage of labour, one to the first and second stages, one to early versus late immersion in the first stage of labour, and another to the
second stage.

We identified no trials evaluating different baths/ pools, or the management of third stage of labour.

Results for the first stage of labour showed there was a significant reduction in the epidural/spinal/paracervical analgesia/anaesthesia rate amongst women allocated to water immersion compared to controls (478/1254 versus 529/1245; odds ratio (OR) 0.82, 95% confidence interval (CI) 0.70 to 0.98, six trials).

There was no difference in assisted vaginal deliveries (OR 0.84, 95% CI 0.66 to 1.06, seven trials), caesarean sections (OR 1.23, 95% CI 0.86 to 1.75, eight trials), perineal trauma or maternal infection.

There were no differences for Apgar score less than seven at five minutes (OR 1.59, 95% CI 0.63 to 4.01, five trials), neonatal unit admissions (OR 1.06, 95% CI 0.70 to 1.62, three trials), or neonatal infection rates (OR 2.01, 95% CI 0.50 to 8.07, five trials).

A lack of data for some comparisons prevented robust conclusions. Further research is needed.

Please click here to read the full article

 

Randomised controlled trial of labouring in water compared with standard of augmentation for management of dystocia in first stage of labour

Posted on by K.D.Brainin

Elizabeth R Cluett, lecturer in midwifery1, Ruth M Pickering, senior lecturer in medical statistics2, Kathryn Getliffe, professor of nursing1, Nigel James St George Saunders, medical director3

Objectives

To evaluate the impact of labouring in water during first stage of labour on rates of epidural analgesia and operative delivery in nulliparous women with dystocia.

Design

Randomised controlled trial.

Setting

University teaching hospital in southern England.

Participants

99 nulliparous women with dystocia (cervical dilation rate < 1 cm/hour in active labour) at low risk of complications.

Interventions

Immersion in water in birth pool or standard augmentation for dystocia (amniotomy and intravenous oxytocin).

Main outcome measures

Primary: epidural analgesia and operative delivery rates. Secondary: augmentation rates with amniotomy and oxytocin, length of labour, maternal and neonatal morbidity including infections, maternal pain score, and maternal satisfaction with care.

Results

Women randomised to immersion in water had a lower rate of epidural analgesia than women allocated to augmentation (47% v 66%, relative risk 0.71 (95% confidence interval 0.49 to 1.01), number needed to treat for benefit (NNT) 5).

They showed no difference in rates of operative delivery (49% v 50%, 0.98 (0.65 to 1.47), NNT 98), but significantly fewer received augmentation (71% v 96%, 0.74 (0.59 to 0.88), NNT 4) or any form of obstetric intervention (amniotomy, oxytocin, epidural, or operative delivery) (80% v 98%, 0.81 (0.67 to 0.92), NNT 5).

More neonates of women in the water group were admitted to the neonatal unit (6 v 0, P = 0.013), but there was no difference in Apgar score, infection rates, or umbilical cord pH.

Conclusions Labouring in water under midwifery care may be an option for slow progress in labour, reducing the need for obstetric intervention, and offering an alternative pain management strategy.

Introduction

Slower than expected progress in the first stage of labour (dystocia) occurs in 20% of nulliparous women in labour and accounts for 20% of caesarean sections and 40% of instrumental deliveries, and results in longer hospitalisation.1 For women at low risk of complications, it marks the transition from midwifery to obstetric management.

Since proponents of active management first claimed the benefits of shorter labour and lower rates of caesarean section,2 3 debate has continued over conservative versus aggressive management and the medicalisation of birth.

Management strategies for dystocia vary from immediate augmentation4 5 to delayed intervention up to four hours after diagnosis.6-8 Comparison between strategies is difficult as specific features often differ; for example, one-to-one care is recognised to have beneficial effect on labour outcomes.9

Our current trial was based on two precepts. Firstly, that incomplete understanding of labour may lead to unnecessarily early intervention. Secondly, that anxiety and pain may trigger a stress response,10 leading to reduced uterine activity and dystocia.11

Labouring in water may ameliorate this stress response by aiding relaxation and pain relief. Few trials have evaluated labouring in water, perhaps because of the difficulty in randomising women who may have strong preferences.12

A Cochrane review concluded that, for women at low risk of complications, there was no clear evidence of advantage or disadvantage in using a pool in labour but further research was needed.13 Two national surveys concluded that labour and birth in water had no effect on perinatal mortality.14 15

In preparation for the trial reported here, we conducted a feasibility study comparing labour in water with augmentation and conservative management for women with dystocia,16 but conservative management was considered unacceptable by women and clinicians. Our current trial therefore compares labour in water with augmentation in nulliparous women with dystocia.

Participants and methods

Design

Our randomised controlled trial compared immersion in water during the first stage of labour after diagnosis of dystocia with augmentation, the standard management for dystocia. We conducted the trial between January 1999 and December 2000 in a large university teaching hospital in southern England with about 4500 births a year.

Study population

Nulliparous women with a diagnosis of dystocia (cervical dilation of < 1 cm/hour)—who at that time would routinely have been advised to have their labour augmented by amniotomy or oxytocin infusion, or both—were eligible for the trial if they were able to give informed consent, had received information about the trial during their pregnancy (a leaflet describing the trial was distributed to all nulliparous women antenatally), were in spontaneous, active labour, and were at low risk of complications (full term, singleton pregnancies, fetus in cephalic presentation, and no medical, obstetric, or psychiatric problems).

Intervention

After participating women were randomised, each management option consisted of a package of care provided by midwives, including one-to-one care. Labour progress was assessed by vaginal examinations every four hours and documented on a standard partogram. All women could request any form of analgesia available at any time.

Augmentation—Women in the augmentation group received the standard management for dystocia. Amniotomy was performed if the membranes were intact, and a midwife managed the labour for the next two hours unless otherwise clinically indicated.

If the membranes were already ruptured or progress was not satisfactory during the two hours after amniotomy, intravenous oxytocin was given, starting at 4 mU/min and doubled every 30 minutes, up to a maximum of 64 mU/min, until regular contractions (3-4 every 10 minutes) occurred. Continuous fetal monitoring was carried out.

Labour in water—Women allocated to labour in water used a permanent, acrylic, oval waterbirth pool measuring 154 cm by 184 cm by 77 cm and filled with still tap water without additives so that immersion was to above the breasts when sitting. Water temperature was maintained at 36.0-37.0°C.

The maximum stay in the pool before reassessment by vaginal examination was four hours. If labour progress was satisfactory (cervicaldilation 1cm/hour),subsequent care could continue in the pool if the woman wished, otherwise augmentation was advised.

Sample size

We based our estimate of the potential effect size on an audit of 50 nulliparous women with dystocia in May-July 1997, who would have met the trial inclusion criteria.

We concluded that 220 women would be required to detect an absolute reduction of 25% in the rate of epidural analgesia (from 60% to 35%) and an absolute reduction of 20% in the operative delivery rate (from 40% to 20%) with 90% power in 5% two sided tests.

The local incidence of dystocia in nulliparous women meeting our eligibility criteria was about five a week (260 a year).

In our pilot study we obtained a consent rate of 71%,16 but we anticipated a lower rate when all midwives undertook recruitment, and therefore planned a recruitment period of two years.

Randomisation and recruitment

We used a computer generated randomisation schedule in balanced blocks of 20. Concealment was ensured by an independent person putting allocation details in sequentially numbered, opaque, sealed envelopes.

Ten consecutively numbered envelopes were stored in the labour ward at any one time and audited daily to ensure they were intact.

After dystocia was diagnosed, a midwife who had received training in patient recruitment checked that the woman in question had received the information leaflet about the trial, assessed her eligibility for the study, and, if suitable, sought her informed consent.

When a woman agreed to participate the midwife opened the next trial envelope to allocate the woman to a treatment arm and to give her a unique trial number. Participation in the trial was recorded in the woman’s routine maternity records.

Outcome measures

Primary outcome measures were epidural analgesia and operative delivery (ventouse, forceps, or caesarean section).

Secondary measures included augmentation rates (receiving amniotomy or oxytocin, or both) and maternal or neonatal morbidity (any infection, admission to the neonatal unit, or condition that required medical care up to the 10th postpartum day).

Obstetric data were recorded in the maternity records by practitioners and abstracted after discharge from maternity care.

It was not possible to conceal allocation from clinical practitioners or at the time of data abstraction as care provided was clearly documented. However, as data were objective in nature and recorded contemporaneously observer bias was minimised.

We conducted a postpartum structured interview in the maternity unit to assess retrospectively the women’s experience of pain at 30 minutes after the intervention started and change in pain over the same time period (measured with visual analogue scales of 0 to 100 mm for pain experience and -50 mm to +50 mm for change in pain).

We did not assess pain concurrently because of the disruption to the women and midwives. We also assessed women’s satisfaction overall and in relation to privacy and freedom of movement (asked as separate questions) using four point Likert scales.

We chose to use a structured interview format to reduce potential bias because it was not possible to keep the interviewer blinded to women’s treatments as their comments made the allocation apparent.

Statistical analysis

We analysed results on an intention to treat basis. We compared rates of epidural analgesia and operative delivery between groups using Pearson’s 2 tests and presented results as relative risks with 95% confidence intervals. When numbers were small we calculated exact P values and confidence intervals in StatXact-5.

We produced numbers needed to treat to produce benefit in one woman and calculated confidence intervals as the inverse of the confidence interval about the absolute risk difference.

Confidence intervals around the numbers needed to treat for non-significant differences include the numbers needed to treat to produce harm,17 showing that results are not inconsistent with the intervention producing worse outcome.

We used Mann-Whitney tests to compare length of labour and women’s pain and satisfaction scores, and presented confidence intervals for differences in means.

A confidential summary of the safety data was prepared after 50 women had been randomised, and assessed by an obstetric consultant independent of the trial, who recommended that recruitment continue.

Results

Recruitment

Of 3825 nulliparous women who delivered in the unit during the two years of recruitment, 741 were defined as being at low risk of complications at the time of the diagnosis of dystocia (see figure). Consent was sought from 176 eligible women, of whom 99 (56%) agreed to participate, and were randomised.

The two groups of women showed no important differences in baseline characteristics (table 1). There was good adherence to the trial protocol, with 48 of the 49 women allocated to labour in water using the pool, and 48 of the 50 women allocated to standard care receiving augmentation.

The woman who declined to enter the water requested an amniotomy. Two women in the augmentation group progressed before augmentation could be started.

Primary outcomes

Twenty three women (47%) allocated to labour in water received epidural analgesia after randomisation compared with 33 (66%) in the augmentation group (relative risk 0.71 (95% confidence interval 0.49 to 1.01), number needed to treat 5) (table 2).

The numbers of operative deliveries (caesarean sections and ventouse and forceps deliveries) were similar in both arms of the trial, with 24 (49%) women allocated to labour in water receiving an operative delivery compared with 25 (50%) women allocated to augmentation (relative risk 0.98 (0.65 to 1.47), number needed to treat 98).

Secondary outcomes

Twenty five of the 27 women in the water labour arm who had made slow progress at the assessment four hours after recruitment received augmentation.

A further three women progressed slowly subsequently and also received augmentation. Seven women who progressed satisfactorily received an amniotomy for other indications.

The number of women who received augmentation (amniotomy or oxytocin) in the water labour arm was significantly lower than that in the standard care arm (35 (71%) v 48 (96%), relative risk 0.74 (0.59 to 0.88), number needed to treat 4) (table 2).

The mean duration of the first stage of labour was similar in the two groups, 10.47 hours in the water labour group and 10.26 hours in the augmentation group (table 3).

Women allocated to labour in water reported significantly lower mean pain scores at 30 minutes after start of the allocated management (49 mm v 64 mm) and a reduction in mean pain (-26 mm) compared with an increase for women receiving augmentation (12 mm).

Women allocated to labour in water were more likely to report satisfaction with freedom of movement (91% v 63%) and with experience of privacy (96% v 81%), but there was no difference between groups in overall satisfaction (table 3).

Maternal and neonatal wellbeing

Maternal and neonatal infection rates were similar in the two groups (table 4), as was neonatal condition at birth indicated by Apgar score and umbilical cord pH. Six neonates born to women in the water labour group were admitted to the neonatal unit compared with none in the augmentation group (P = 0.013).

The reasons for admission were: cardiac defects (1), hypothermia (2), fever (1), suspected infection on day 2 (1), and poor feeding on day 3 (1). There was a mean delay of 6 hours (range 2-10 hours) between women leaving the pool and birth.

With the exception of the infant with cardiac defects, all these neonates, who had required an operative delivery, were reunited with their mothers within 48 hours and experienced no subsequent problems.

Discussion

This is the first trial to evaluate the impact of labouring in water for nulliparous women with dystocia. Compared with women given standard augmentation, the women labouring in water had no difference in operative delivery rates and tended to receive less epidural analgesia.

Before this trial it had been suggested that as all the women would have dystocia, augmentation would be inevitable, along with longer labour, and/or assistance in the second stage of labour.

However, almost 30% of women in the water arm did not receive augmentation and 20% received no obstetric intervention, without evidence of longer labour, both of these rates being significantly different from the augmentation arm. In addition, women retrospectively reported less pain and increased satisfaction.

Our findings suggest that delaying augmentation in association with a supportive environment (water immersion) is acceptable to women with dystocia and may reduce the need for epidural analgesia without increasing labour length or operative deliveries.

This is important, as it has been suggested that women prefer earlier intervention.7

Also a management approach that reduces rates of augmentation and associated obstetric intervention may contribute positively to maternal physiological and psychological health: oxytocin infusion is known to increase the risk of uterine hyperstimulation and fetal hypoxia, and obstetric interventions are associated with lower maternal satisfaction.18

A reduced need for epidural analgesia and augmentation may enable staff and other resources to be used differently—for example, allowing more women to receive one-to-one care in labour.

Maternal and neonatal wellbeing

The trial was not large enough to detect differences in maternal and fetal morbidity. However, indicators of wellbeing were similar in the two groups, with the exception of increased admission to the neonatal unit after labour in water.

Possible reasons for this include the water immersion itself, the delay in intervention of up to four hours (even though this did not affect overall labour length), extra caution by practitioners when women were known to have laboured in water, or chance factors with no direct relation to the trial.

No other studies of labour in water have reported such an association: instead, they either did not provide data on admissions to neonatal units19 20 or reported only one admission21 or similar admission rates in both trial arms.22

Eckert et al reported an increased incidence of initial resuscitation measures with water immersion,22 but we found no difference in Apgar scores and blood gas analysis at birth.

Indeed, three of the admissions to the neonatal unit were between nine and 48 hours after delivery, while the three admissions immediately after birth were associated with temperature regulation.

Comparative studies of labour in water found no increase in admissions to neonatal units or other markers of neonatal distress.23-25 It is clearly important to ensure ongoing audit of neonatal outcomes for women who labour in water.

Limitations of study

Only 99 of the intended 220 women were recruited for a variety of reasons. In common with other trials18 epidural analgesia was the main reason why nulliparous women with dystocia were ineligible for our study (28%).

Local rates of epidural analgesia and their likely impact on recruitment should feature as part of the planning of any future trials involving labour management.

In our busy maternity unit recruitment was not a priority, and some eligible women were not invited to participate in our study. The main reason eligible women chose not to enter the trial was a preference for one or other form of care (40%).

This is a recognised problem, and consideration is needed on how this may affect the generalisability of our findings and ways to overcome recruitment problems.

Recruitment became more difficult towards the end of the trial because of the adoption of a more conservative approach to managing dystocia in the unit and the introduction of the modified World Health Organization partogram,6 which incorporates a delay between the identification of slow progress and augmentation.

During this delay midwives could facilitate ongoing conservative management; as a consequence, they were less willing to recruit women to the trial, knowing that half of the women would immediately receive augmentation.

Thus, the trial was not continued past the planned two years. The low recruitment rate contributed to the outcomes achieved, such as the lack of statistical significance in relation to the difference in rates of epidural analgesia.

    • What is already known on this topic

For women in normal labour, immersion in water is associated with less need for analgesia and increased satisfaction

Augmentation of labour, in particular oxytocin administration, is associated with hyperstimulation and decreased maternal satisfaction

    • What this study adds

For nulliparous women with dystocia (cervical dilation < 1 cm/hour), immersion in water for up to four hours seemed to reduce need for augmentation of labour, reduce pain, and increase satisfaction, without increasing overall length of labour or operative delivery rate

Water immersion may be an alternative option to early augmentation of labour

We thank the women who participated in the trial; the midwives and obstetric and support staff of the unit where the trial was conducted; research advisory group members Maggie Elliot and Debbie Gould; and Rona McCandlish for her support in preparing this paper.
Contributors: ERC was principal investigator and research midwife and was responsible for trial design and coordination, and data collection and analysis, supported by RMP and KG as research supervisors. NJS contributed to the initial idea and enabled the trial in the clinical setting.

All authors helped to write the paper. ERC acts as guarantor for the paper.
Funding: Southampton University Hospitals NHS Trust.
Competing interest: None declared.
Ethical approval: Approval was given by the local research ethics committee.

References

  1. Department of Health. NHS maternity statistics, England 1989/90 to 1994/95. Statistical Bulletin No 28. London: Stationery Office, 1997: 1-16.
  2. Johanson R, Newburn M, MacFarlane A. Has the medicalisation of childbirth gone too far? BMJ 2002;324: 892-5.
  3. Impey L, Boylan P. Active management of labour revisited. Br J Obstet Gynaecol 1999;106: 183-7.
  4. Cammu H, Van Eeckhout E. A randomised controlled trial of early versus delayed use of amniotomy and oxytocin infusion in nulliparous labour. Br J Obstet Gynaecol 1996;103: 313-8.
  5. Sadler LC, Davison T, McCowen LME. A randomised controlled trial and meta analysis of active management of labour. Br J Obstet Gynaecol 2000;107: 909-15.
  6. World Health Organisation maternal health and safe motherhood programme. World Health Organisation partograph in the management of labour. Lancet 1994;343: 1399-404.
  7. Blanch G, Lavender T, Walkinshaw S, Alfirevic A. Dysfunctional labour: a randomised trial. Br J Obstet Gynaecol 1998;105: 117-20.
  8. Lavender T, Walkinson S, Walton I. A prospective study of women’s views of factors contributing to a positive birth experience Midwifery 1999;15: 40-6.
  9. Hodnett ED. Support from caregivers during childbirth. (Cochrane review) In: Cochrane Library. Issue 1. Oxford: Update Software, 2003.

   10. Brownridge P. The nature and consequence of childbirth pain. Eur J Obstet   Gynecol Reprod Biol 1995;32(suppl): S9-15.

  1. De Punzio C, Neri E, Metelli P, Bianchi MS, Venticinqui M, Ferdeghini M, et al. The relationship between maternal relaxation and plasma beta endorphin levels during parturition. J Psychosom Obstet Gynaecol 1994;15: 205-10.
  2. Garland D, Jones K. Waterbirth, first stage immersion or non immersion? Br J Midwifery 1994;2(3): 113-20.
  3. Nikodem VC. Immersion in water during pregnancy, labour and birth. In: Cochrane Library. Issue 1. Oxford: Update Software, 2003.
  4. Gilbert RE, Tookey PA. Perinatal mortality and morbidity among babies delivered in water; surveillance study and postal survey. BMJ 1999;319: 483-7.
  5. Alderdice F, Renfrew M, Marchant S, Ashurst H, Hughes P, Berridge G, et al. Labour and birth in water in England and Wales. BMJ 1995;310: 837.

16. Cluett ER, Pickering RM, Brooking JI. An investigation into the feasibility of comparing three management options (augmentation, conservative and water) for nulliparae with dystocia in the first stage of labour. Midwifery 2001;17: 35-43.

17. Altman DG. Confidence intervals for the number needed to treat. BMJ 1998;317: 1309-12. 18. Green JM, Coupland VA, Kitzinger JV. Great expectations. A prospective study of women’s expectations and experiences of childbirth. 2nd ed. Cheshire: Books for Midwives, 1998. 19. Schorn MN, McAllister JL, Blanco JD. Water immersion and the effect on labor. J Nurse Midwifery 1993;38: 336-42.

  1. Rush J, Burlock S, Lambert K, Loasley-Milman M, Hutchinson B, Enkin M. The effects ofwhirlpool baths in labour: a randomised controlled trial. Birth 1996;23: 136-43.
  2. Cammu H, Clasen K, Wettere L, Derde M-P. To bathe or not to bathe during the first stage oflabor. Acta Obstet Gynecol Scand 1994;73: 468-72.
  3. Eckert K, Turnbull D, MacLennan A. Immersion in water in the first stage of labour: arandomised controlled trial. Birth 2001;28: 84-93.
  4. Aird IA, Luckas MJM, Buckett WM, Bousfielf P. Effects intrapartum hydrotherapy on labourparameters. Aust N Z J Obstet Gynaecol 1997;37: 137-42.
  5. Otigbah CM, Dhanjal MK, Harmsworth G. A retrospective comparison of water births and conventional vaginal deliveries. Eur J Obstet Gynecol Reprod Biol 2000;91: 15-20.

25. Ohlsson G, Buchhave P, Leandersson U, Nordstrom L, Rydhstrom H, Sjolin I. Warm tub bathing during labor; maternal and neonatal effects. Acta Obstet Gynecol Scand 2001;80: 311- 4.



Position Paper No 1a – The use of water in labour and birth

Posted on by K.D.Brainin

Immersion in water during labour was popularised as a formal method of analgesia by Odent in the 1970s (Beake 1999), and became widespread after the Winterton Report recommended that all maternity services provide women with the option to labour or deliver in water (House of Commons Health Committee, 1992).

As with all aspects of midwifery care, the use of water during labour and birth requires evaluation of associated benefits and risks, yet there are no large, collaborative, randomised controlled trials to date (Nikodem, 2000).

This paper clarifies the RCM’s position and recommendations to its members. It should be used in conjunction with local policies and guidelines.

Introduction It has been estimated that 50 per cent of maternity units now provide facilities for labour or birth in water, and that between 15% and 60% of the women attending those units choose to use these facilities.

The number of births occurring in water is much lower, however; between April 1994 and March 1996, a survey identified only 0.6% of births in England and Wales occurring in water, 9% of which were home births (Tookey and Gilbert, 1999).

These averages conceal wide variation, with some units passively or actively discouraging women from using water, while one birth centre reports up to 80% of women using water during labour, with up to 79% giving birth within the pool (Beech, 2000).

There is not enough evidence to evaluate the use of immersion in water during labour (Nikodem, 2000), but both potential benefits and adverse effects have been described in the literature. Beneficial effects include maternal relaxation, less painful contractions, shorter labours, less need for augmentation, less need for pharmacological analgesics, more intact perinea, and fewer episiotomies (Schorn et al, 1993; Garland and Jones, 2000).

Among the adverse effects discussed are unrealistic labour expectations, restricted mobility, infection, and the potential problem of the neonate inhaling water (Alderdice et al, 1995; McCandlish and Renfrew, 1993).

The systematic review produced by the Cochrane Library highlights that ‘although no significant adverse effects have been reported, the possibility of adverse outcome for the neonate should not be ignored’ (Nikodem, 2000).

There is clearly a need for more research, and midwives should give high priority to developing midwifery knowledge in this area. In the meantime, the available evidence does not justify discouraging women from choosing this increasingly popular option.

Women experiencing normal pregnancy, who choose to labour or deliver in water, should be given every opportunity and assistance to do so. RCM recommendations

1. All maternity units should develop policies and guidelines, underpinned by the available evidence, on the use of water in labour and birth. These should be developed in consultation with midwives, supervisors, and local user representatives.

2. Managers and supervisors should ensure that midwives acquire and sustain the competence, skills and confidence necessary to assist women who choose to labour or deliver in water (UKCC, 1992a; UKCC, 1992b; UKCC, 1998a).

3. Midwives should ensure they are competent to provide support to women who choose to use water, and should keep themselves updated on the research evidence in this area.

4. Midwives should audit and evaluate their practice, and the outcomes of labour and birth in water, in order to contribute to midwifery knowledge and the development of best practice.

5. All midwives should ensure their record keeping of labour and births in water is accurate and adheres to UKCC standards (UKCC, 1998b). Policies and guidelines for the use of water Every maternity unit should have, or should develop, policies and guidelines on the use of water in labour and birth.

These should be underpinned by the best available evidence, and should be developed in consultation with supervisors and user representatives. They should cover the following areas:

1. Professional expertise

The assistance of women to labour and deliver in water should be considered a core midwifery competence. However, some will have lacked experience in this area, and therefore appropriate education, training and supervision will be necessary. Continuing professional development in this area should be seen as a service requirement.

2. Information for choice

• All women should be offered information on the option of using water in labour and birth. There are no grounds for seeing this option as particularly suitable for, and acceptable to, certain groups of women on the basis of non-clinical criteria.

• All women who express an interest in the use of water should be given full verbal and written information, including where appropriate a copy of the unit’s policy. This should include any expectations of the woman (for example, on the supply of equipment), and what steps will be taken in the event of an emergency.

3. Criteria for use of water Criteria for use of water may include:

• Women’s informed choice
• Normal term pregnancy at 37+ weeks
• Singleton fetus with cephalic presentation
• No systemic sedation
• Spontaneous rupture of membranes < 24 hours Other non-clinical criteria – such as the availability of staff or equipment – may reasonably be deployed; however, as with all other areas of maternal choice, their obstruction of women’s informed decision-making should be actively kept to a minimum.

4. Equipment

• Local policies should specify essential and desirable equipment for the use of water, and make clear who is responsible for supplying it. • All unit equipment should conform to British Safety Standards, and be checked by the Health and Safety Officer (RCM, 1998). 5. Health and safety
• Local infection control policies should cover the use of water in labour and birth, and midwives should ensure they implement universal precautions (RCM, 1998).
• Specialist health and safety advice should be sought to develop policies on pool cleaning.
• Health and safety advice on moving and handling should be adhered to at all times (RCM, 1999).

6. Additional professional issues

• Temperature: All midwives should understand the physiological basis of maternal and fetal hyperthermia, local guidelines should specify target temperatures for the water during delivery and birth (Steer and Deans, 1995; Garland and Jones, 2000). Maternal, core water and room temperatures should all be checked regularly.

• Analgesia: Local guidelines for the use of additional pain relief should be developed in consultation with an anaesthetist, and discussed with all women prior to labour. These should cover all forms of pain relief, including complementary therapies.

• Birth: Local guidelines should be developed to guide midwives on best practice during delivery. These should be underpinned by the best available evidence (Nikodem, 2000).

• Emergencies: Local guidelines should detail what steps are expected in an emergency situation. All midwives, and all women using water for labour or birth, should know and understand these steps.

References

Alderdice F, Renfrew M, Marchant S, Ashurst H, Hughes P, Berridge G, Garcia J (1995) Labour and birth in water in England and Wales: survey report. British Journal of Midwifery 3(7): 376-382 Beake S (1999) Water birth: a literature review. MIDIRS Midwifery Digest 9(4): 473-477 Beech B (2000) Waterbirth: time to move forward. AIMS Journal 12(2): 1-2 Garland D and Jones K (2000) Waterbirth: supporting practice with clinical audit. MIDIRS Midwifery Digest 10(3): 333-336 House of Commons Health Committee (1992) Second Report on the Maternity Services (Winterton report). HMSO: London McCandlish R and Renfrew M (1993) Immersion in water during labour and birth: the need for evaluation. Birth 20(2): 79-85 Nikodem V (2000) Immersion in water in pregnancy, labour and birth (Cochrane Review). In: The Cochrane Library, Issue 2. Update Software: Oxford RCM (1998) Health and Safety Representatives’ Handbook. RCM: London RCM (1999) Handle With Care: a midwife’s guide to preventing back injury. RCM: London Schorn M, McAllister J, Blanco J (1993) Water immersion and the effect on labour. Journal of Nurse Midwifery 38(6): 336-342 Steer PJ and Deans AC (1995) Labour and birth in water: temperature of pool is important. British Medical Journal 311(7001): 390-1 Tookey P and Gilbert R (1999) Perinatal mortality and morbidity among babies delivered in water: surveillance study and postal survey. British Medical Journal 319(7208): 483-487 UKCC (1992a) Scope of Professional Practice. UKCC: London UKCC (1992b) Code of Professional Conduct. UKCC: London UKCC (1998a) Midwives Rules and Code of Practice. UKCC: London UKCC (1998b) Guidelines for records and record keeping. UKCC: London Further reading Brown L (1999) The Tide Has Turned: audit of water birth. British Journal of Midwifery 6(4): 236-43 Burns E and Kitzinger S (2000) Midwifery Guidelines for Use of Water in Labour. Oxford Brookes University: Oxford Jessiman C Byers H (2000) The Highland experience: immersion in water. British Journal of Midwifery 8(6): 357-361 Lawrence Beech BA (1996) Water Birth Unplugged: the proceedings of the first International Water Birth Conference. Books for Midwives Press: Cheshire UKCC (1994) Position Statement – Waterbirth. UKCC: London

Acknowledgements This paper was developed with the assistance of Dianne Garland (Practice Development Midwife, Maidstone), YP Choo (Labour Ward Co-ordinator, Chelsea and Westminster Hospital) and Mary Coe (Community Midwife, Southampton). October 2000 Royal College of Midwives