Category: Water Birth Articles

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).

Health Times: Karen Keast

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Professor Gamble agrees.

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

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

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

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

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

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

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

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

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

“I really love water births.”

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

This response is known as the ‘dive reflex’.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

 

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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.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

It states:-

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

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

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

REFERENCES:

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

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

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

United Kingdom Central Council position statement on waterbirths 1994

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

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

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

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

STAGE OF LABOUR?

A. Labour 32°c- 36°c

Birth 36°c- 37°c

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

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

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

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

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

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

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

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

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

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

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

Q. WHEN TO LEAVE THE WATER?

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

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

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

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

In my experience I have never known it.

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

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

Q. HOW OFTEN SHOULD THE FETAL HEART BE MONITORED?

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

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

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

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

During the first stage of labour every 30 mins

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

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

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

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

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

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

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

Wearing gloves is essential:_

TIP

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

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

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

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

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

Q. WHAT OBSERVATIONS ARE REQUIRED?

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

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

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

That she is not over or under heated.

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

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

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

The woman who has mild hypertension.

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

WHAT ABOUT VAGINAL EXAMINATIONS?

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

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

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

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

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

The emphasis should be on the normal mechanism of labour.

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

Equipment required and useful for a waterbirth’-

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Q WHAT IF THE CORD IS TIGHT AROUND THE NECK?

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

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

Q WHAT ABOUT THE RISK OF THE CORD SNAPPING?

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

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

These suggestions may help. –

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

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

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

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

ESTIMATING BLOOD LOSS IN WATER?

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

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

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

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

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

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

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

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

FAINTING

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

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

Always have syntometrine available.

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

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

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

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

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

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

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

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

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

WHAT IS THE CONCERN REGARDING WATER EMBOLISM?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

WHAT ABOUT THE PERINEUM?

Technically conducting a waterbirth is a “hands off procedure”

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

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

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

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

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

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

SHOULDER DYSTOCIA & WATERBIRTH

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

RISK FACTORS: – Exclusion for birth in water

Large for dates baby

Poor progress in first stage, early second stage of labour

Previous history.

Midwives “gut feeling”

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

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

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

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

Remember record keeping relating to shoulder dystocia is very important.

E.g.

Not time of perineal phase of the second stage of labour

Note first indication of the shoulder dystocia

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

Episiotomy attempted or reasons for not performing

Positions used to facilitate delivery

Manoeuvres used to facilitate delivery

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

Baby.

Details of any resuscitation if required.

TWINS & WATERBIRTH

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

HOW DOES THE MIDWIFE LOOK AFTER HER BACK?

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

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

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

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

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

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

SUGGESTED READING: –

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

RCM 1998 health & Safety representatives handbookRECORD KEEPING

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

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

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

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

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

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

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

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

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

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

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

   WOMEN SHOULD BE URGED TO LEAVE THE POOL IF:

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

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

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

(Observer newspaper January 28, 2004)

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

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

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

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

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

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

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

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

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

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

Other studies have confirmed the pain relieving effects of water.

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

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

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

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

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

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

How water birth originated

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Extract from “Water Birth” by Janet Balaskas

How water can help you in labour

“The water looked very inviting and I was delighted with it when I got in. I had a fire burning and the room was candle lit, with soft music and lavender oil in a burner.”

The change in how a woman feels and behaves soon after entering a birth pool in a quiet darkened room can be remarkable. It seems to alter her state of consciousness and her concentration – sometimes dramatically – so that she very soon relaxes and sinks more deeply into herself and is able to let herself surrender to the involuntary rhythms of her labour. It’s as if she becomes sleepy, even dreaming.

In the ‘Birth and the Family Journal (Vol 8)’ Michel Odent writes: ‘The reason why kneeling or immersion in water during labour is so helpful is mysterious. What is clear is that water is often the way to reduce inhibitions… we observe that during such immersion in warm water, semidarkness is the best way to reach a high level of relaxation. Water may be a good way to reduce adrenergic secretion. Immersion in warm water with semidarkness may also be a way to reach alpha brain wave rhythms.

Water may be a symbol of mother, of comfort, regression to childlike needs and behaviour. Whatever way we want to talk about the effect of water during labour, one thing is sure.

The contractions become more efficient and less painful at the same time, so that sometimes the labour is very quick. Many women do not want to leave the pool because it is so comfortable. As a result sometimes the baby comes while the mother is in the pool.’

The benefits of water immersion, or hydrotherapy, in labour have been studied and assessed by many experienced midwives, researchers and doctors all over the world.

It is clear from common findings that including a pool of warm water in the birthing room adds a whole new dimension to the experience of childbirth. A recent study of 1,300 water births found that the use of a birth pool is rated very highly by women, whether having their first or subsequent baby and their enthusiasm is shared by midwives.

This echoes the findings of thousands of women and their midwives all over the world. There are some women who have had several water labours or births and have had such satisfactory experiences that they cannot imagine giving birth in any other way.

But just as every labour is unique, no two women will use a birthing pool in quite the same way. Moreover, a minority of women who try the pool do not find it helpful.

Many women however, are very keen to get into the pool at the earliest possible moment (although we will see later that it is not wise to get in too early) and some are so comfortable that they want to stay in the water for the whole of the remaining labour and birth.

Others find the pool helpful for pain relief during labour, but feel the need to be on dry land for the birth itself. A further group may labour and give birth on land but use the pool for relaxation after the birth.

In a long slow labour, episodes in the pool can be useful for resting. The message is that water can be of benefit in a variety of ways.

“My labour was very short and intense. Near the end I wanted to get my head down to slow the pain down When I went into the pool I found that I couldn’t get my head down lower than my hips as I had been doing out of the water, so I felt the contractions more strongly than ever. I got out because I missed the presence of my husband to cling to and overall felt very isolated in the pool.”

Privacy and non-intervention

One of the benefits of labouring in a pool is the sense of privacy that most women who use it experience. Enclosed in her private space, protected by the gentle barrier of the water, a woman can feel secure from unwanted contact and more in control of her body. She is free to turn her attention inwards and focus on the rhythms of her labour and what she needs to do to ride the powerful sensation of the contractions.

Although it is essential that regular fetal monitoring is carried out periodically while the mother remains in the pool, in practice there are fewer internal examinations and other procedures than in most labours on land.

And, significantly, this ‘hands-off’ approach seems to have no adverse effect on mother or baby as was noted in a study of 2,000 women in a hospital in Switzerland where water birth is offered as an option to every woman.

“I was glad not to need any stronger pain relief (I had an epidural for the birth of my first baby) and to give birth naturally feeling in total control in the pool and in my own home. I liked the fact that being in the pool meant that the midwives keep a hands-off approach and leave it up to you with no internal examinations and no breaking of the waters. It was so different from my first experience.”

Midwives who attend water births often have to develop different ways of assessing progress in labour. Instead of routine vaginal examinations to check dilation, the midwife relies on more subtle indicators, such as the woman’s breathing, vocalisations and movements.

In fact, many midwives feel that attending labours and births in water has added an extra dimension to their midwifery skills, including an extra sensitivity to changes in the mother without the need for manual confirmation.

Pain relief through water

“The pool helped the labour to progress rapidly… I was very eager to get in the water and found it a huge relief when I entered… the pool was very useful in coping with the pain, helping to focus me so I could concentrate on making the pain useful and positive.”

One of the main reasons that women choose to use water during their labour is for the relief of pain. There is no doubt among midwives experienced in its use, that immersion in water can provide dramatic relief of discomfort for a high proportion of women.

Various studies have confirmed this finding. For example a clinical audit of water births carried out in five birthing units in England, ‘supported the proposition that water birth is effective as a method of pain relief.’

In hospital birthing units that have a long-standing commitment to the provision of pool facilities and support from birth attendants who feel at ease with using water in this way, there has been a dramatic reduction in the use of analgesic drugs such as pethidine (meperidine in the US).

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

A systematic review of three randomised control trials exploring immersion in water in labour only (not birth) found that there was a significant decrease in the use of medical pain relief in the women who used a birth pool in labour – indicating that for some women the use of a birth pool provides an effective alternative route to epidural anaesthesia.

Epidurals have become very sophisticated and generally provide effective relief from pain and can be used very positively in some circumstances. You need to be aware that using a birth pool will not eradicate the pain in the same way as an epidural – but works indirectly by helping significantly through the benefits listed below, to make it easier for you to tolerate and manage the pain yourself.

Summary of benefits of labouring or giving birth in water

• Increases privacy
• Provides significant pain relief
• Reduces the need for drugs and interventions
• Encourages a woman’s sense of control in labour
• Facilitates mobility and enables the woman to adopt optimal positions for an active birth
• Speeds up labour
• Promotes relaxation and conserves energy
• Helps to reduce tears
• Is rated highly by mothers and midwives
• Encourages an easier birth for the mother and a gentler welcome for the baby

Excerpt from “The Waterbirth Book”: by the World-Renowned Natural Childbirth Pioneer Janet Balaskas

   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!

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.

 

Australian College of Midwives – 2013

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

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

Key principles

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

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

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

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

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

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

Achieving best practice

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

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

Resources to guide practice

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

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

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

In recent years, professional organizations that represent maternal-child health care providers have taken various positions on the recommended use of immersion hydrotherapy during labor and birth. The resulting lack of consensus has made consistent and equitable access to this non-pharmacologic method for pain relief in labor challenging.

This model practice template was jointly developed by representatives from the American Association of Birth Centers, American College of Nurse-Midwives, Midwives Alliance of North America, National Association of Certified Professional Midwives, and other experts to offer guidance to health care professionals and institutions that provide or are implementing hydrotherapy services. This document is informed by the most current available information and resources that support best practices and serves as an outline of the various roles and responsibilities involved in providing hydrotherapy during labor and birth. Limited information has been published on the efficacy and safety of specific care practices before, during, or after hydrotherapy. However, this document is informed by the methodologically-sound, peer-reviewed studies that have been published to date. The format of this model practice template allows for adaptation depending on the setting and the maternity care professionals involved to support the development of individual practice guidelines and institutional policies and procedures.

DISCLAIMER

This document is specific to considerations regarding hydrotherapy during labor and/or birth and is provided as an educational aid to members of the endorsing organizations and interested maternity care providers. This model practice template is not intended to dictate an exclusive course of management or to substitute for individual professional judgment. It presents recognized methods and techniques of clinical practice that maternity care providers may consider incorporating into their practices. The needs of an individual client or the resources and limitations of a particular setting or type of practice may appropriately lead to variations in clinical care. The information in this document is gleaned from published literature available through April 2016. This document will be reviewed against newly available scientific evidence and/or every 5 years after initial publication.

Water birth pools serve a pivotal role in enhancing the experience of physiological labour and natural childbirth for mothers.

In fact, they are particularly effective in helping mothers manage pain without relying on analgesia for relief (National Institute for Health and Care Excellence, 2014).

Research has shown that women who enter a warm water pool during established labour are better equipped to cope with the pain associated with childbirth.

Immersion in warm water has been unequivocally proven to offer significant physiological and psychological benefits during labor (Cluett et al., 2004).

The benefits extend beyond pain management; women who choose water birth often report a heightened sense of fulfillment and accomplishment, while babies experience a gentler, less traumatic birth process (Royal College of Obstetricians and Gynaecologists, 2014).

In addition to these advantages for mothers and babies, midwives also experience increased job satisfaction, and healthcare facilities can save resources and costs by providing water birth options (National Institute for Health and Care Excellence, 2014).

Statistics from the National Maternity Survey in 2014 indicate that nearly a third of women in the UK benefited from using a water birth pool (Care Quality Commission, 2014).

With up to 60% of mothers showing interest in natural birth, it is opportune to consider expanding the availability of this safe, cost-effective approach (American College of Obstetricians and Gynecologists, 2017).

On dry land, mothers face the challenge of gravity, which limits their movement as labor progresses and fatigue sets in.

Many women may lack the physical fitness required to maintain upright postures for extended periods (Gupta et al., 2007).

Additionally, mothers who are overweight or obese may struggle to cope with the physical demands of labor (Vahratian et al., 2005).

The transition from land to water can rejuvenate and energize mothers, providing them with a newfound sense of purpose.

The buoyancy of water reduces a mother’s relative weight by approximately 33%, allowing her to move in ways that would be impossible on land and explore natural labor and birthing postures (American College of Nurse-Midwives, 2014).

Furthermore, the warm water’s calming and relaxing effects promote the release of oxytocin, a critical hormone in childbirth.

Oxytocin induces uterine contractions and triggers the “fetal ejection reflex,” further aiding the birthing process.

Immersion in water has been shown to have a positive physiological impact on hormone secretion, including oxytocin surges that can facilitate cervical dilation and stimulate contractions (Odent, 2014).

In conclusion, water birth pools offer a multifaceted approach to childbirth that benefits both mothers and babies, enhances midwives’ job satisfaction, and provides cost-effective options for healthcare facilities.

The evidence supports the integration of water birth as a valuable and safe method to promote natural childbirth and physiological labor experiences.

Why Active Birth Pools are the No. 1 choice world-wide

Active Birth Pools from a midwives perspective

Active Birth Pools from a mothers perspective

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

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

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

Click here for PDF of full article

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

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

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

Click here for a PDF of the full article

Choosing a Water Birth – Harrogate NHS Trust

Your Guide to Water Birth – Northumbria HealthCare Trust