Category: Water Birth Articles

Childbirth is a transformative experience, and every expectant mother deserves the opportunity to have a comfortable and empowering birthing experience.

For plus-size women, the challenges of labour and delivery can sometimes be compounded by their body size.

However, one increasingly popular option that offers numerous benefits is labouring in water.

This article explores the advantages of water labour specifically for plus-size women, highlighting how it can enhance their birthing experience and overall well-being.

Buoyancy and Weight Support

One of the primary benefits of labouring in water for plus-size women is the buoyancy and weight support provided by the water.

As water buoys the body, it reduces the gravitational pull on joints and muscles, making it easier for women with larger body sizes to move and change positions during labour.

This buoyancy can alleviate the pressure on the pelvis and lower back, which is especially important for plus-size women who may already experience discomfort in these areas due to their size.

Reference: Geissbuehler V, Stein S, Eberhard J. Waterbirths compared with land births: an observational study of nine years. J Perinat Med. 2004;32(4):308-314.

Pain Relief and Relaxation

Warm water has a natural analgesic effect, helping to ease the pain and discomfort associated with labour contractions.

Plus-size women may have additional challenges due to their size, such as increased strain on the body, making the soothing properties of water particularly beneficial.

Water labour can promote relaxation, reduce stress, and create a calming environment, allowing mothers to focus on their breathing and coping techniques.

Reference: Harper SG, Lynch M, Vernacchio L. “Waterbirth: a retrospective comparative study of waterbirth and land birth outcomes.” Journal of Perinatal Education. 2002;11(2):22-29.

Improved Blood Circulation

For plus-size women, carrying extra weight can sometimes lead to issues with blood circulation and swelling in the extremities.

Immersing in warm water during labour can improve blood circulation by promoting vasodilation, which can help reduce swelling and alleviate discomfort.

Improved circulation can also support the baby’s oxygen supply during contractions.

Reference: Mollamahmutoglu L, Moraloğlu Ö, Ozyer S, et al. Warm showers as an alternative to warm sponges for the management of third stage of labour. European Journal of Obstetrics & Gynaecology and Reproductive Biology. 2002;101(1):19-23.

Enhanced Mobility and Positioning

Water labour allows for greater freedom of movement, which is especially valuable for plus-size women.

The buoyancy of water makes it easier to change positions, squat, or kneel, providing a range of options for comfort and facilitating the progress of labour.

The flexibility to find a comfortable position can be especially important for plus-size women, as it may help prevent complications and reduce the need for interventions.

Reference: Cluett ER, Burns E. Immersion in water in labour and birth. Cochrane Database of Systematic Reviews. 2009(2):CD000111.

Reduced Stress on Joints

The extra weight carried by plus-size women can put strain on their joints and ligaments, potentially leading to discomfort during labour.

Immersion in water can reduce the stress on joints, making movements smoother and less painful.

This can be particularly advantageous during the pushing phase of labour, as it allows for better control and coordination of efforts.

Reference: Zanetti-Daellenbach R, Tschudin S, Zhong X, et al. Influence of immersion in water on uterine contractility and cerebral oxygenation during the first stage of labour. Am J Obstet Gynecol. 2007;196(5):468.e1-8.

Conclusion

Laboring in water offers numerous benefits to plus-size women, enhancing their birthing experience and promoting a sense of empowerment during childbirth.

The buoyancy and weight support of water, coupled with its pain-relieving properties and improved circulation, make it a valuable option for managing the unique challenges associated with labouring while plus-size.

Ultimately, the decision to labour in water should be made in consultation with a healthcare provider, taking into account individual preferences and medical considerations.

Nevertheless, it’s clear that water labour can provide a positive and supportive environment for plus-size women, contributing to a more comfortable and fulfilling childbirth experience.

Active Birth Pools are designed to cater to the specific needs of plus-size women during childbirth

Our pools boast a spacious and ergonomic structure that allows for comfortable movement and positioning during labor.

Their wider dimensions and sturdy construction provide ample room and support for plus-size mothers, ensuring they can find comfortable birthing positions without constraints.

The carefully engineered design also takes into consideration accessibility, making it easier for expectant mothers of all sizes to enter and exit the pool safely.

These pools are equipped with features like grab rails and steps to ensure stability and ease of use.

In essence, the design of active birth pools prioritizes inclusivity and comfort, empowering plus-size women to have a positive and fulfilling birthing experience.

The use of water birth pools has gained popularity in recent years as expectant mothers seek alternatives that enhance the natural birthing experience.

One of the key factors contributing to the success of water births is the warm water in the birthing pool, creating an environment that encourages the release of oxytocin.

Often referred to as the “love hormone” or “bonding hormone,” oxytocin plays a crucial role in the progression of labour and the overall well-being of both mother and baby.

Understanding Oxytocin:

Oxytocin, produced by the hypothalamus and released by the pituitary gland, is a hormone known for its role in promoting social bonding, emotional connection, and uterine contractions during childbirth.

It is often associated with feelings of love, trust, and intimacy, and its presence is pivotal in the birthing process.

The Warm Water Effect:

Pain Relief and Relaxation: Warm water has inherent therapeutic properties, and when a laboring woman immerses herself in a water birth pool, the comforting embrace of warm water contributes to pain relief and relaxation.

The buoyancy of water alleviates the pressure on the body, reducing muscle tension and creating an environment conducive to calmness.

As the mother relaxes, the body is more apt to release oxytocin, facilitating the progression of labor.

Enhancing Blood Circulation:

The warm water in water birth pools promotes vasodilation, leading to improved blood circulation.

This enhanced blood flow is particularly beneficial during childbirth, as it ensures that the uterus receives an adequate supply of oxygen and nutrients.

The improved circulation helps in optimizing uterine contractions and, subsequently, the release of oxytocin.

Reducing Stress Hormones:

Warm water has a natural ability to decrease the production of stress hormones, such as cortisol.

By creating a serene and comfortable environment, the water birth pool minimizes the stress response, allowing the body to focus on the release of oxytocin.

This reduction in stress hormones supports a positive birthing experience and contributes to the mother’s overall well-being.

Facilitating the Bonding Process:

Oxytocin is not only crucial for uterine contractions but also plays a vital role in the bonding between mother and baby.

The warm water in the birthing pool promotes the release of oxytocin, fostering a sense of intimacy and connection between the mother and her newborn.

This early bonding experience can have lasting positive effects on the emotional well-being of both mother and child.

Promoting a Positive Birth Environment:

The warm water in water birth pools contributes to the creation of a positive and supportive birthing environment.

This positive ambiance, coupled with the physiological effects of warm water, enhances the mother’s overall experience, making her more receptive to the natural release of oxytocin.

Conclusion:

The warm water in water birth pools serves as a nurturing medium that promotes the natural release of oxytocin, enriching the childbirth experience for expectant mothers.

As healthcare providers and birthing centers continue to recognize the benefits of water immersion during labor, understanding the interplay between warm water and oxytocin release becomes essential.

By harnessing the therapeutic properties of warm water, the journey through childbirth becomes not only more comfortable but also profoundly connected, nurturing the beautiful bond between mother and baby.

A way to make labour shorter, easier and more comfortable

Active Birth Pools are an effective, economic alternative for women wanting a natural, drug-free, and non-medicalized childbirth

 

Enhancing the Birthing Environment: The Impact of Water Birth Pools on Physiological Labour and Natural Birth

 

 

Originally published December 11, 2014

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

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

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

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

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

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

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

Birth in water is safe and effective

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

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

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

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

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

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

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

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

Complicated waterbirthing pools are not necessary.

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

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

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

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

Waterbirth is here to stay

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

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

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

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

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

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

Exploring movements in Water

Sheila was a keen proponent of water birth.

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

 

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

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

Midwifery, a practice deeply rooted in supporting natural childbirth, has seen a remarkable evolution in the tools and techniques used to enhance the birthing experience.

Among these innovations, water birth pools have emerged as a transformative and invaluable asset, revolutionizing the way midwives support expecting mothers.

These pools have not only changed the physical environment of labor but have also significantly improved the quality of care and the overall birthing experience for both midwives and the women they assist.

Creating an Ideal Birthing Environment

Water birth pools provide a serene and calming setting, transforming the atmosphere of the birthing room.

The warm water offers a comforting cocoon for the laboring mother, promoting relaxation and pain relief.

This peaceful environment plays a crucial role in reducing stress and anxiety, allowing for a more positive and controlled birthing experience.

Benefits for Midwives

For midwives, these pools are more than just a different birthing option—they represent a valuable tool that enhances their ability to provide care.

Here’s how water birth pools make a difference for midwives:

1. Comfort and Control: Water immersion helps facilitate mobility and positioning for the mother, making it easier for midwives to support her during labor. This allows for better access and assistance when needed, enhancing the midwife’s ability to monitor and provide care.
2. Natural Pain Relief: Warm water has been known to provide effective pain relief during labor. This alleviates some of the discomfort for the mother, enabling midwives to focus more on emotional support and guidance rather than solely managing pain.
3. Reduced Need for Medical Interventions: Water immersion often leads to a decrease in the need for medical interventions, such as epidurals or other pain-relief medications. Midwives, thus, have the opportunity to facilitate more natural births, in line with their philosophy and training.
4. Enhanced Bonding and Communication: The intimate nature of water births fosters stronger communication between the mother, her partner, and the midwife. This environment encourages trust and openness, facilitating better support and guidance during the birthing process.

Challenges and Considerations

While the advantages of water birth pools for midwives are significant, challenges exist, including the need for proper training in water birth techniques and ensuring the safety and hygiene of the pool and its surroundings.

Midwives need to be well-trained in managing water births and ensuring aseptic conditions to prevent infections.

The Future of Midwifery with Water Birth Pools

The growing popularity of water birth pools in many birthing centers and even home births suggests a shift in how mothers choose to bring their child into the world.

This, in turn, influences the practice of midwifery.

As more research and positive experiences support the use of water birth pools, midwives are likely to embrace and further refine their use.

Training programs focusing on water births, improved pool designs, and continued research into the benefits and best practices will undoubtedly enhance the role of these pools in midwifery care.

Conclusion

Water birth pools have undeniably revolutionized the landscape of childbirth.

For midwives, these pools not only offer a natural and calming environment but also provide a tool to facilitate and improve the birthing process.

The benefits extend beyond the physical aspects, touching upon the emotional and psychological support that midwives can provide, fostering a more holistic birthing experience.

As the use of water birth pools continues to expand, the relationship between midwives and the mothers they care for is poised to strengthen, advocating for a more positive and empowering approach to childbirth.

Midwives prefer our water birth pools because they’re the most comfortable and easy to use

Active Birth Pools: Manual Handling

Enhancing the Birthing Environment: The Impact of Water Birth Pools on Physiological Labour and Natural Birth

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

Here are the facts…

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

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

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

Hospital staff and resources can be employed more efficiently.

Importantly – this results in significant financial savings!

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

Click here to learn more about our water birth pools and find out how they will deliver for you.

 

 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

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

Nothing helps mothers cope with pain more effectively.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

This powerful hormone plays a huge role in childbirth.

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

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

   The introduction of birthing pools in the UK began in the late 1980’s and is one of the greatest innovations to happen in natural childbirth. More than 150 hospitals in the UK now (2001) have at least one installed pool and hundreds of portable pools are also in circulation. The use of water for labour and birth is increasing and has been under intense scrutiny in the last 10 years. The outcomes of the research have so far, been positive. The help of water to enable more women to give birth naturally is very relevant at this time, when one in 5 babies in the UK is born by caesarean section.

   The invigorating and therapeutic value of water is well know to all of us – from our daily bath or shower to mineral springs, saunas and spa’s, rivers, oceans – all places we go to for healing and regeneration. These qualities are brought into the labour room when we introduce a pool of warm water. This is a wonderful way to transform the atmosphere in a hospital and to encourage normal birth physiology.

   Long before there was modern plumbing, water was used as a birth aid in many cultures. It’s soothing, cleansing, and healing properties were used to help women in labour and it was also used as a birth stimulant.

The benefits of using a birth pool

   Water is a feminine element. It is buoyant and soft and carries your body’s weight. As soon as you enter the water, the warm, sensual sensations on your skin remind you that your labouring body is beautiful, powerful, and sensual. Although this is not the case for everyone, the majority of women comment that they were surprised by how wonderful and relieving it felt when they first got into the pool.

   Water pools help many women to cope better with pain and enhances those passions and deep emotions which are an integral part of a healthy birth. For many women a birth pool provides an alternative route to an epidural and can be the key to a physiological birth. The water is not likely to take away the pain, but it can make a tremendous difference to your ability to relax and may well make the pain more bearable.

   Studies have shown that endorphine levels may go down in a birth pool – a sign that pain levels decrease. A birth pool is something to try before considering an epidural or other form of medical pain relief. You can always change your mind if you need to.

   The buoyant effect of the water completely supports your body’s weight. This gives you a feeling of physical liberation – like being in warm ocean. Resting between contractions is much easier, because being in the water is so comfortable and relaxing. This helps tremendously to conserve your strength and energy, so you are less likely to become fatigued or exhausted.

   In the pool you are in your own womblike space – you are in charge. It’s more difficult to disturb or distract you. A birth pool represents a sanctuary from what some women experience as the menace of obstetric routines. In water your body is your own territory – your birth attendants need your consent to get close to you.

   The water’s buoyancy also helps enormously to make you more comfortable in upright positions. You can move more easily and spontaneously help your baby to descend and rotate by yourself.

  You will be surprised to find that it’s much easier, for example, to squat in water. Even women who find squatting difficult on land, can often do so comfortably in water — with the added benefit that this position makes a lot more space in the pelvis for your baby to descend.

   Once in the pool, you are unlikely to notice how much time has passed. Many women say that the world beyond the rim of the pool seems to disappear.This increased sense of privacy in the pool helps you to concentrate on working through your contractions without any distractions.

   The relaxing environment helps you to let go of what is happening around you and to focus your awareness inwards on the work your body is doing and surrender to the rhythm of your labour.

   The oxytocin wave – how entering a birth pool effects hormone secretion.

   Water birth pioneer, Dr Michel Odent, in his latest updates on water birth, suggests that there is a correlation between the findings of physiologists on the effects of water immersion on hormone secretion and the observations of midwives that labours tend to slow down when the woman enters the pool too early.

   He suggests that immediately after a woman enters the pool, there is a surge of oxytocin which stimulates contractions and results in rapid dilation. However this effect is short lived and after about 1.5 – 2 hours, oxytocin secretion reaches a peak and begins to slow down. The timing of when you enter the pool therefore becomes important.

Practical tips and guidelines

   When to get in – If you are planning to use a birth pool it’s best to stay out of the water in the latent phase of labour. At this time, using upright positions, movement and breathing awareness, complementary therapies or TENS can help you to get into a comfortable rhythm with your labour (see Issue nos 8 and 10)

   .In mid labour, when you are about 5 – 6 cms dilated – around the time when many women ask for pain relief – is the best time to think about entering a birth pool (our experience also shows that getting in too early can slow down contractions). Getting in late means that you are likely to be close to full dilation at the crest of the oxytocin wave.

   In a long labour, contractions may slow down in the pool and then it is best get out and use the help of gravity on dry land for a while, resting in the pool later if you get tired.

   The golden rule of water labour and birth – if progress is slow in water try land, if slow on land try water

   The water temperature is important. Because your baby relies on you for temperature regulation and is one degree warmer than you are, the temperature of the water should never exceed 36C in labour and is best at 36C or 37C for the birth itself. When you feel cold, hormone secretion is inhibited and this will weaken your contractions. If you feel warm enough but not hot, you have probably got it just right for you. Measuring the temperature with a water thermometer is important, but don’t worry about it being too exact! How you feel is the best test.

   The ideal water temperature range in labour is 32C-36C and for birth around 36C-37C

  Water depth – You also need to make sure that in labour the water is deep enough to cover your belly and allow your shoulders to be exposed, so you can sweat and loose heat if you need to. Immediately after the birth there is often a need to remove some of the water, so you can breastfeed in the pool with the water keeping your baby’s body warm with his or her head out of the water at breast level.

   Birthing rooms with a pool are warm and humid, so make sure that there is good ventilation and the room is not over heated. Plenty of drinking water for everyone is also a good idea, as a humid atmosphere is dehydrating.

   Your partner can sit right beside you in the pool or even get in with you to massage, hold and comfort you. As you share the same environment, there is no increased risk of infection if your partner enters the pool! So it’s a good idea to have a swimsuit ready for your partner, just in case.

    If this idea doesn’t appeal to you, it’s still very easy to share the intimacy of labour with your partner seated nearby, outside the pool. Having a low stool or a birth ball beside the pool is useful for your partner and for the midwife. Many women value having all the space in the pool to themselves, while others enjoy the comfort and support of relaxing against their partner’s body in the water.

* The Midwife’s practise

   It is a transforming experience for a midwife to be around women in a birth pool. It is understandable that midwives contemplating their first water births may be nervous and feel insecure. Until very recently their education would not have included Water Birth. The health authority generally prefer two midwives to be at a water birth.

   The fact that you are in water does not greatly change the midwife’s usual practice – in fact it makes it considerably easier, because the warm water helps you to cope better by yourself. She will need to make the normal observations of both your and your baby’s well being and the progress of your labour.

   Vaginal exams can be kept to a minimum and can be done when necessary in the pool.

   Monitoring the baby’s heartbeat at regular (probably half hourly) intervals is important to ensure that there is no foetal distress. However the midwife needs to be sensitive to avoid disturbing you too much – a waterproof sonic aid allows monitoring under water so you do not need to change your position or break your concentration. Alternatives are a stethoscope, a long stemmed pinnard or a regular sonic aid with the transducer in the finger of a long glove. A non water proof sonic aid may mean that you need to float close to the edge or sit up on the edge of the pool.

    The midwife will check your body temperature and blood pressure at times and keep an eye on the temperature of the water.

  When a birth pool is introduced into a hospital birthing room the environment is transformed into one which is much more homelike. The pool invites the mother to relax and there is usually no delivery bed in sight. The atmosphere of fear and danger are eradicated and everyone’s expectations about what will happen are different. There is a deliberate attempt to induce feelings of confidence and relaxation in the mother.

   This makes a hospital environment more attractive if you want a physiological birth with the security of obstetric support close at hand. At a home birth the environment is even more ‘hormone enhancing’ when a birth pool is available and there is a powerful resource to help you cope with pain in the active stage of labour.

   In the pool room it’s a good idea to dim the lights or draw the curtains to reduce stimulation so that there is a peaceful, calm and intimate atmosphere. When you can really relax in labour, as a birth pool helps you to do – you can let go more easily and things usually go well. It’s not a problem if you want or need to get out for the birth. You will have achieved the most important objective, which is a more comfortable labour, without the need for drugs or interventions.

How to use Water during Labour:
How long and When to Stay in the Water

   The attraction to water and the timing of using the water pool is very individual and varies from one woman to another and one labour to another. If pre-labour contractions are intense and there are long runs of contractions prior to the onset of established labour, water can be extremely soothing.

   After staying in water for some time the contractions may diminish, giving you an opportunity to rest and maybe even fall asleep, thus conserving your energy for the subsequent labour and birth.

   When labour is well established, the timing of using the pool once again shows a wide individual variation. After entering the water dilation is often rapid during the first h our. It is preferable to keep the pool in reserve for the second half of labour when the contractions are intense and the periods of rest shorter.

   This is when water is most powerful in assisting dilation and shortening labour. However, you might need the comfort of water from quite early on in labour and want to spend hours in the pool prior to the birth itself. In this instance you can go in and out of the pool and alternate between being in water and being on land.

   When the pool is used early, mothers sometimes tire of the water and they may not want to use this valuable resource later on when contractions become more painful and intense. Getting in too early may slow down contractions and prolong labour.

   Provided the correct water temperature is maintained and your temperature is monitored, it is safe to stay in the water as long as you like. The depth of the water is also important. The more your body is submerged the more help you will get from buoyancy.

   However, women’s preferences vary. While some like the water to be as deep as possible, others are more comfortable in less water.

   When you leave the pool it is advisable to have plenty of large towels available so that you can dry yourself completely. There should also be a heater in the room so that if you feel cold the temperature can be raised quickly.

Movements and Positions

   There are bound to be times when you prefer to need to be outside the pool on dry land during your labour, for example, if labour is not progressing well in water or if you do not feel like being in water. In early labour, as your contractions are beginning to intensify it is essential to make the most of the help of gravity.

   You can do this by using positions such as standing, sitting or squatting during your contractions and resting between them. Follow you instincts when moving during labour and you will find that these positions occur spontaneously.

   Most women use a variety of positions. Some prefer one or two while other women are more restless and change position frequently. During contractions movements such as circling your hips or rocking your pelvis can help to dissipate the pain.

   There are many ways to make yourself comfortable in upright positions so that you do not tire yourself out. It i s useful to bear in mind that the more vertical or upright your body is the more help you will get from gravity. When standing or walking you may find it helpful to lean forward onto a wall or to be held by your midwife or partner during the contractions.

   When kneeling make sure your knees are resting on a soft surface and use a firm beanbag or pile of cushions to make yourself comfortable to relaxing between the contractions and to make sure that your trunk stays fairly vertical.

   You may want to rest lying on your side, well propped up by cushions between contractions. For squatting, a low stool is very helpful and makes squatting less tiring. You can also hold onto a firm support or squat between your partner’s knees while he sits on a chair.

   Sitting on the toilet with your knees spread apart is very comfortable in labour and for many women the privacy of the bathroom is appealing. Here you can fill the basin and splash yourself with water if you want to and enjoy the sound of running water from the tap.

Entering the Pool

    Once you enter the pool, water powerfully increases your sense of privacy and adds a new dimension to the range of positions and movements you can use. The buoyancy of the water makes it much easier to move and change position and you will find that you will change positions instinctively and movement will occur spontaneously.

   It’s helpful to experiment in the pool or in a swimming pool in the days before your labour begins, and to submerge your head under water at times so that you feel completely familiar and at ease in the water. This is a way to block out sounds which are distracting.

   You will find that most of the movements and positions you can use on land can be used in water during contractions.

    Floating between contractions is a wonderful way to relax, and wetting your hair and going under the water at times reduces outside stimulation and sounds and helps you to let go. there is a wonderful sensuous quality to being in water in labour.

   It is like reconnecting with the original primal feelings you had in the womb. This is a tremendous aid to surrendering to the birth energy and to letting your body’s natural rhythms take over.

   There is no need to do anything. It will help if the room is darkened and you have enough privacy. With the water as deep as possible you can use your ability to relax and quieten your mind to sink deeply into your labour.

   Some women remain quite still in the water, changing positions occasionally, whereas others like to move a lot, rolling from front to back like a mermaid, or a dolphin.

  Movements and position changes will happen without you needing to think about them. Between contractions you can rest and benefit from the restorative and energising properties of the water.

    You can sink into its nurturing and feminine energy and accept its power to relax you. If you can let go completely you will rest, your energy will recharge and you will enter into a kind of timeless ocean of bliss between the contractions.

The End of Labour

   As the birth of the baby approaches contractions will be at their most intense. They will be longer (lasting up to sixty seconds) and closer together so that the intervals are very brief.

   This is the peak of labour when the ocean waves are high and turbulent, following upon each other with relentless frequency. The end of labour is usually referred to as ‘the transition stage’. You are close to full dilation and your baby’s head is about to emerge through the dilated cervix into your vagina ready to be born.

   It is normal to feel fearful at this stage. This is the time when you are likely to wish you could get away or have an epidural anaesthetic, when your courage and strength may be at a very low ebb.

   You may feel angry and irritable or despairing, as if you are exhausted and almost close to death. The breaks between your contractions may give you little respite before the next contraction looms large, like a tidal wave.

   It is very helpful to make the most of the respite between contractions and rest and relax deeply, almost sleeping until the next wave begins. this can restore and replenish your energy surprisingly – even though the gaps are short.

   The fear which is common at this stage has an important role to play. It triggers off a surge of adrenalin secretion, the ‘fight or flight’ hormone which stimulates the reflexive contractions which expel your baby during birth.

   At this time you are on the threshold of giving birth. This is when the powerful demon goddess takes over as the urge to bear down and give birth arises.Outside stimulation including sound and light or touch should be minimal, as you go through these last demanding contractions without distraction.

   You will be in an altered state of consciousness, deep inside your labour. Anyone who is present will need to be very discreet and avoid disturbing you, by watching, talking or by being falsely reassuring or anxious.

   This time can also be difficult for birth attendants and partners who may feel an intense desire to do something to help. However, their calm silence can be a source of strength, reassurance and encouragement as you go through the intensity of the end of labour.

   Some women are deeply afraid of the birth at a subconscious level and may experience difficulty in surrendering to the power of these final contractions. Being in warm water helps to let go. Often this intense phase passes very quickly or has a kind of timeless quality.

   However, if transition is long, you can keep up your energy by sipping water or dilute fruit juice. Most women feel very thirsty when the adrenalin response begins and need to drink a glass or two of water. The bach flower remedy called ‘Rescue Remedy’ can be very helpful.

   At this time near to the birth, the sounds emerging from the birth room tend to be loudest, so there is no need to try to be quiet. You will be in your full power, so feel free to roar like a lioness if you need to .

   Noise will help you to find the power to assist your baby to come down as your body opens to give birth. Your bowels empty spontaneously as your baby’s head presses down and you may need to retch as the expulsive reflex begins.

   Some women feel shy or inhibited about letting go to to these natural reflexes in the presence of other people. It helps to remember that your midwife is used to this and will welcome these events as a sign that the birth is imminent. Whatever happens your concentration will be focused deeply on the power of your contractions with moments of brief but blissful serenity in between them.

   At this stage you may feel that you are almost drowning in a sea of contractions. You may wish to leave the water, or alternatively surrender to the power in the weightlessness which its buoyancy allows you.

   Whether you are in or out of the pool, it is best to use the positions which feel most comfortable, making sure that you can relax, with your body supported between contractions. The water level in the pool should be as high as possible to offer you maximal support.

   As birth approaches, many women prefer kneeling. This position helps to give you a sense of control over the intensity of the contractions and makes it easier to relax or even sleep in the brief intervals between them without moving or changing position.

   At the very end of labour, contractions often slow down and the resting phases may lengthen. The contractions which expel our baby from the womb usually begin around the time full dilation of the cervix is reached.

   In some women the urge to push may start before dilation is complete and sometimes, on the other hand, there is a break or resting period before expulsion begins. This will feel like a lull, a period of time where suddenly the waves become still and the sea becomes calm.

   The lull may continue for quite a while before the pushing urge begins. On the other hand you may begin to feel the urge to bear down much earlier. Whatever happens you can trust in the wisdom of your body and surrender to its urges. Soon your baby will be born!

Bridge to Health –  Sian Smith

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

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

Here are some of the reasons why:

Water is relaxing!

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

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

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

Water is a natural pain reliever

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

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

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

It reduces stress and anxiety

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

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

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

It reduces the risk of perineal tearing

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

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

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

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

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

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

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

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

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

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

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

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

It is safe!

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

BigBirtha.co.uk...

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

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

Professional advice for attending midwives

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

2. Adequate education

3. Professional and peer support

4. Familiarity with legal implications

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

5. Record Keeping

6. Health and Safety

7. Rehearse Emergency Procedures

8. Midwife’s Comfort

Preparation of Parents

Aqua natal and other antenatal classes

Midwife explains use of the pool

Discuss:

File notes of parent’s wishes

Parents to agree in advance

However

Midwife on duty must be competent and willing

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

“Midwives are accountable for their own practice”

PREPARING THE POOL ROOM

Portable Pool

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

Remove all unnecessary furniture.

2. Place blue disposable liner in position

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

Put filling pipes over the side of the pool.

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

As pool is filling, adjust creases in liner.

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

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

5. Clean up any spillage – remove unnecessary hose.

6. Equipment Required

Parents’ birth plan

Admission

1. Confirm mother still wishes to use the pool

2. Base line observations

3. Assess strength of contractions

4. Obtain satisfactory CTG

5. Vaginal assessment

Avoid rupture of membranes

AIM – Physiologically normal labour

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

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

Use:

Aromatherapy Massage

Homoeopathy

Labour – Inclusion criteria

Labour – Exclusion criteria

Caring for the mother and baby in the pool

Labour

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

Disturb as little as possible

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

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

3. Adjust depth of water for comfort

4. Lower lights

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

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

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

8. Ventilation and room temperature to comfort.

Observations during Labour

Amniotomy

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

Pain Relief

1. Warm water may be enough

2. Breathing, visualization, relaxation techniques

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

4. Homoeopathy

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

6. Verbal support – partner participation

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

Elimination

1. Inclusion of toilet in pool room preferable

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

Birth in water

Exclusion Criteria

Second Stage in the pool

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

Two midwives present

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

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

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

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

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

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

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

Mother and father welcome baby, take photographs etc.

First sucking takes place.

Third stage in water

Exclusion Criteria:

First contact between mother and baby undisturbed if possible.

Discreet, unhurried observations

Placenta:

A physiological third stage is logical after a natural birth.

Use oxytocic drugs only if blood loss is excessive

Emptying a portable pool

Dealing with Emergencies

If in doubt – Get her out!

Cord around neck

Remember: NEVER cut the cord prior to underwater delivery

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

Shoulder dystcoia

Episiotomy Procedure

Episiotomy is rarely needed for a water birth

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

Not difficult to do in the pool

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

Call for assistance.

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

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

Midwife maintains airway until assistance arrives.

Assistance Arrives

Baby slow to breathe

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

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

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

Keith Brainin – Founder & Director Active Birth Pools

Birth under water – Michel Odent

Originally published in the Lancet: 1983

Centre Hospitalier Général de Pithiviers, PIthiviers 45300, France

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

REFERENCES

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

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

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

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

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

 

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

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

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

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

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

Water supply

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

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

Bodily fluids, birthing ‘debris’ and maternal contamination

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

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

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

 Drains

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

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

Birthing pool design

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

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

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

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

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

Resolving issues

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

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

References

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

This response is known as the ‘dive reflex’.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

 

SaveSave

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

It states:-

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

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

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

REFERENCES:

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

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

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

United Kingdom Central Council position statement on waterbirths 1994

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

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

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

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

STAGE OF LABOUR?

A. Labour 32°c- 36°c

Birth 36°c- 37°c

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

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

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

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

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

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

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

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

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

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

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

Q. WHEN TO LEAVE THE WATER?

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

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

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

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

In my experience I have never known it.

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

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

Q. HOW OFTEN SHOULD THE FETAL HEART BE MONITORED?

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

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

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

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

During the first stage of labour every 30 mins

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

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

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

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

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

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

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

Wearing gloves is essential:_

TIP

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

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

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

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

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

Q. WHAT OBSERVATIONS ARE REQUIRED?

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

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

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

That she is not over or under heated.

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

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

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

The woman who has mild hypertension.

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

WHAT ABOUT VAGINAL EXAMINATIONS?

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

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

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

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

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

The emphasis should be on the normal mechanism of labour.

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

Equipment required and useful for a waterbirth’-

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Q WHAT IF THE CORD IS TIGHT AROUND THE NECK?

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

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

Q WHAT ABOUT THE RISK OF THE CORD SNAPPING?

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

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

These suggestions may help. –

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

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

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

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

ESTIMATING BLOOD LOSS IN WATER?

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

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

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

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

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

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

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

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

FAINTING

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

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

Always have syntometrine available.

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

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

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

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

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

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

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

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

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

WHAT IS THE CONCERN REGARDING WATER EMBOLISM?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

WHAT ABOUT THE PERINEUM?

Technically conducting a waterbirth is a “hands off procedure”

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

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

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

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

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

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

SHOULDER DYSTOCIA & WATERBIRTH

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

RISK FACTORS: – Exclusion for birth in water

Large for dates baby

Poor progress in first stage, early second stage of labour

Previous history.

Midwives “gut feeling”

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

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

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

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

Remember record keeping relating to shoulder dystocia is very important.

E.g.

Not time of perineal phase of the second stage of labour

Note first indication of the shoulder dystocia

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

Episiotomy attempted or reasons for not performing

Positions used to facilitate delivery

Manoeuvres used to facilitate delivery

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

Baby.

Details of any resuscitation if required.

TWINS & WATERBIRTH

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

HOW DOES THE MIDWIFE LOOK AFTER HER BACK?

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

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

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

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

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

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

SUGGESTED READING: –

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

RCM 1998 health & Safety representatives handbookRECORD KEEPING

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

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

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

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

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

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

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

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

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

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

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

   WOMEN SHOULD BE URGED TO LEAVE THE POOL IF:

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