By Chantelle Winstanley (Consultant Midwife)
Submitted by Alyson Brown
Natural Birth Centre Lead Midwife
Queen Mary Maternity Unit
West Middlesex University Hospital
Benefits and rationale for use
Criteria for use
Care during first stage of labour
Care during second stage
Care during third stage
Emergency procedures in the pool
Cleaning the pool
Group B streptococcus
Fetal monitoring in labour
Ratified by Maternity Services Forum – November 2013
Changes since last update – Infectious Diseases p4
Review Date – November 2016
Labour and Birth in Water
When utilising this guideline to support women who may wish to use water for labour and / or birth, a full discussion must take place between the women and her caregiver to ensure the benefits and potential challenges concerning the use of water have been highlighted.
Where possible, informed decision making should allow for a distinction to be made between ‘Hydrotherapy,’ that is, the use of immersion in the water to ease the discomfort of labour and ‘Waterbirth;’ the term used to indicate that the baby has been born directly into warm water.
Following discussion during the antenatal period or upon admission in labour, it is good clinical practice to document a woman’s preferred option in relation to hydrotherapy for labour and waterbirth. Midwives can refer to pages 14-16 of ‘Birth and Beyond’ leaflet (2012)’ to aid a discussion.
BENEFITS AND RATIONALE FOR USE
Evidence which supports a positive experience for women who choose to labour and / or birth in the water is well documented.
Maternal satisfaction is increased by feeling more relaxed in the water, feeling more in control and more involved in decision-making (Richmond 2003; Hall and Holloway, 1998.)
Hydrotherapy may offer benefits to women owing to feelings of weightlessness, ease of mobility due to water buoyancy, warmth, deep relaxation and the principle of facilitating and accentuating normal childbirth (Odent, 1998; Garland, 2011.) Odent (1998) suggests that the deep relaxation obtained from warm water promotes rapid cervical dilation.
In addition, there is robust evidence to prove that water is a useful analgesic in labour, resulting in less use of epidural and spinal anaesthesia following immersion in the water (Cluett and Burns, 2009.)
There is some evidence to suggest that women who choose a waterbirth sustain reduced perineal trauma, owing to the counter-pressure of the water encouraging steady maternal pushing and a slow delivery of the baby’s head (Garland, 2011.)
A joint statement by the RCOG / RCM, published in 2006, supports the principle of hydrotherapy for healthy women with uncomplicated pregnancies (RCOG / RCM, 2006.) Whilst they state that the evidence for birthing in water is less clear, Cluett and Burns (2009) found that, in comparison to land births, there was no significant difference in the type of birth, Apgar scores (at 5 minutes), admission to NNU and neonatal infection.
Likewise, there is no evidence to support the notion that the use of water in labour and birth increases perinatal morbidity and mortality (Alderice et al 1995; Gilbert and Tookey, 1999.)
CRITERIA FOR THE USE OF WATER IN LABOUR AND BIRTH: HOSPITAL AND HOME SETTING
- Uncomplicated singleton pregnancy; long lie and cephalic presentation
- 37 – 42 weeks gestation
- Spontaneous onset of labour; regular, painful contractions
- Normal fetal heart rate
- Maternal observations remain within normal limits
- Absence of bleeding greater than a blood-stained show
- Absence of meconium
- Ruptured membranes for <48 hours* (see Prelabour spontaneous rupture of membranes and Group B streptococcus).*Women with ruptured membranes >24 hours, in an otherwise uncomplicated pregnancy at 37-42 weeks, who make an informed decision for expectant management of labour should not be excluded from hydrotherapy / waterbirth providing that SROM is within 48 hours of the onset of established labour.The liquor should be clear, with no signs of infection or odour with an absence of meconium, known GBS or maternal pyrexia. Vigilant maternal and fetal observation is paramount in these circumstances. Should any concerns arise, the midwife should encourage the woman to leave the water immediately. Following birth, the newborn should be closely observed for a minimum of 12 hours in cases of ruptured membranes >24 hours.
- Absence of narcotic analgesia: It is not advisable for women who have received opiate analgesics to enter the pool. Women should be clear of sedation symptoms before using water in labour– a recommended time frame is 2-4 hours following the administration of either pethidine or Meptid; midwives should make an assessment of sedation levels before the woman enters the pool.
- Women with known GBS in current pregnancy: Women with known GBS are not excluded from the use of water, providing intrapartum antibiotics have been offered in established labour. Care should be taken to ensure that infection control principles are adhered to i.e waterproof dressing is applied to the cannula.Women with known GBS and pre-labour ruptured of the membranes (PROM) will be offered immediate IOL (therefore excluded from the use of water.) If women decline IOL and choose expectant management <24 hours there is no current evidence available to suggest that water in labour increase the risk of neonatal / maternal infection in these cases. A full discussion should take place with the woman regarding the risks of GBS / PROM, including liaison with the Obstetric and Paediatric teams.
Special Circumstances: women who fall outside of the criteria for the use of water in labour and birth:
- A woman should be given the opportunity to discuss her requests with the Consultant Midwife and/or Consultant Obstetrician in the antenatal period. SoMs are also available to support discussions on maternal choice.
- Women who request a waterbirth but fall outside of the criteria should have a clear plan made and documented based on informed choice, preferably before labour commences. If the plan changes during labour, and midwives are uncertain if the use of water is an appropriate option, they should contact the Supervisor of Midwives (SoM) on call or discuss with the labour ward co-ordinator on duty.
- All discussions should be thoroughly documented concerning the benefits and risks of using the pool where risk factors are present.
- Clinical staff should respect that women have a right and choice to opt for a water birth when high risk factors are present.
- For higher-risk cases where continuous electronic fetal monitoring (cEFM) is recommended, the use of telemetry should be encouraged and Room 6 on labour ward should be prioritised (where possible) to reflect a woman’s request.
Infectious Diseases and Waterbirth
There is no evidence on the safety of water for women with known viral infections. Trust infectious diseases consultants have advised that any woman with HIV and a plan for a vaginal birth will have an undetectable viral load and therefore may use the pool.
Women who are chronic carriers of hepatitis B i.e. ‘e’ antigen negative may also use the pool but those with hepatitis C who are PCR positive i.e. detectable viraemia should not. There will be evidence of discussion and a plan in the notes of women with viral infections.
PREPARING FOR A WATERBIRTH AT HOME
- Prepare a resuscitation area for the baby – ensure a flat surface; check equipment and have x2 cord clamps prepared in the rare event of cord snapping
- Prepare an area for the mother to get out of the pool safely in the event of an emergency
- Ensure that the partner understands they are responsible for filling / empting the pool. Record the temperature as in a hospital pool birth
- Ensure that there is sufficient mobile phone signal to call 999 in the event of an emergency
- Midwives are responsible for their own professional development; only midwives competent in the principles of waterbirth are to care for women requesting hydrotherapy in labour. Support and training is available in the use of water for labour and birth (RCOG / RCM 2006); midwives should speak to the Consultant Midwife or Practice Development team should they require training in this area.
- When caring for a woman using a birthing pool, back care is important. Minimise bending where appropriate.
- If possible, encourage the woman to lift her abdomen out of the water to enable fetal heart auscultation.
- Use gauntlet gloves in the second stage; avoid becoming excessively wet
CARE DURING FIRST STAGE OF LABOUR
- There is little evidence available for the use of arbitrary points during labour to dictate when pools should or should not be used (RCM, 2012.) Women are recommended to enter the pool when contractions are strong, regular and painful.
- Prepare a safe place to exit the pool, if required, in the event of an emergency.
- Check neonatal resuscitation equipment.
- Comfortable room temperature (21-28o C)
- Record the water temperature and maternal temperature hourly. RCOG/RCM (2006) suggests that it may be of more benefit to allow women to regulate the pool temperature to their own comfort in the first stage of labour. As a guide, the water temperature can be maintained below <37.5 o C (Gordon, 1996; Garland; 2011)
- Maternal observations (temp / pulse) and progress should be recorded hourly (with the exception of maternal BP)
- The fetal heart should be auscultated with an underwater sonicaid and recorded as for intermittent auscultation on land (see Fetal monitoring in labour)
- Water should be deep enough to facilitate movement and comfort, but not so deep that there is a risk of the cord snapping when the baby is brought to the surface. Therefore water should be at the level of the woman’s nipples.
- Aromatherapy oils should not be used in the water.
- Whilst in the pool, the woman may use Entonox for pain relief.
- Exiting and re-entering the pool should be determined by the woman as she wishes (RCOG/RCM, 2006.) As a guide, encourage the woman to exit the pool every 2 hours to empty her bladder.
- One midwife, trained and competent in water births, to remain with the woman throughout labour.
- Allow the woman to adopt any position she finds comfortable.
- Encourage adequate hydration throughout
- If delivery is not imminent within 4 hours of entering the pool, the woman should leave the pool for a period of time. She may then re-enter the pool providing her contractions regain regularity and fetal heart patterns are normal.
CARE DURING SECOND STAGE
- Regulation of water temperature is important in the second stage of labour – maintain water temperature at around 37.0 o C to prevent fetal initiation of respiration under water (Johnson, 1996)
- It is a recommendation that 2 midwives be present when birth appears imminent
- Prepare birth equipment. X2 cord clamps are recommended.
- Careful intermittent auscultation of the fetal heart every 5 minutes for 60 seconds following a contraction.
- The instinctive, expulsive contractions observed in the second stage may be quite different from that which midwives observe on a bed-based or land birth. Directed pushing is not normally required when a woman is submerged in the water; she will often make instinctive responses to the descending fetal head and control the speed with short pushes.
- It is important the baby is born totally immersed in the water at the point of birth. During crowning, some women have an uncontrollable urge to lift their bottom up out of the water; this presents a risk to the infant. In this circumstance, the midwife should gently encourage the woman to re-immerse in the water by placing her hand on the woman’s lower back or thigh to guide her.
- Birth in water is often gentle and relaxed. The infant may take up to a minute to respond. If no sign of breathing is apparent after one minute, clamp and cut the cord, call for emergency assistance, wrap the infant in a clean, dry towel and place on a flat surface and initiate neonatal resuscitation if required.A “hands off” approach is strictly necessary to avoid stimulating the baby and causing initiation of respiration under water. Feeling for the nuchal cord or exerting manual counter pressure on the emerging head is against recommendation and is potentially harmful. DO NOT attempt to clamp and cut a tight cord under water.
- A mirror may be used to aid visualisation and assess progress of the second stage.
- As far as possible, faecal contamination in the pool should be removed using a sieve. In the event the pool becomes heavily contaminated, it may be necessary to ask the woman to temporarily leave the pool whilst it is emptied, cleaned and re-filled.
- Following delivery of head and shoulders, the midwife and / or woman should gently bring the baby head first to the surface. The air will stimulate respiration (Gordon, 1996; Johnson, 1996).
- The baby’s body should be kept under water to prevent hypothermia.
- Birth in water is often gentle and relaxed. The infant may take up to a minute to respond. If no sign of breathing is apparent after one minute, clamp and cut the cord, call for emergency assistance, wrap the infant in a clean, dry towel and place on a flat surface and initiate neonatal resuscitation if required.
Slow Progress in the second stage
If progress is slow or not apparent, consider:
- Maternal and fetal condition and maternal behaviour – all observations within normal limits?
- Changing maternal position for pushing, possibly leaving the pool
- Encouragement – use of a mirror to view progress?
- Emptying the bladder
- Is the woman adequately hydrated?
Birth would be expected to take place within 3 hours following full dilatation for nullips and 2 hours for multips as for a dry birth.
The woman must leave the pool if there is a deviation from normal.
CARE DURING THIRD STAGE
Physiological third stage
Women who have experienced an uncomplicated first and second stage of labour should be able to choose a physiological third stage following full discussion.
It should be left to maternal choice whether the woman exits the pool for delivery of the placenta (physiological third stage only); the risk of water embolism is entirely theoretical and there are no known cases (Wickham, 2005.)
Midwives should be aware that it is difficult to identify if a woman is having a PPH in the pool.
- Determine the woman’s choice and ensure all is normal
- Do not clamp and cut the cord; doing so disturbs normal physiology and may predispose to a retained placenta or PPH.
- Keep the infant immersed in the warm water at approximately the same level as the uterus to prevent possible excessive transfusion to the baby.
- Allow the woman to expulse the placenta sitting upright in the water: ensure the water is maintained at 37 o
- If there is any delay or signs of excessive bleeding, assist the woman to leave the pool immediately. Initiate active management in this case.
- If the woman wishes to leave the pool for physiological third stage, clamp and cut the cord following cessation of pulsation, pass the baby to a birth partner and assist the woman out of the pool. Keep mother and baby warm with dry towels and encourage skin-to-skin and early suckling. An upright position is recommended. Remove the clamp from the placental end of the cord and allow the blood to drain into a receiver to facilitate separation and expulsion of the placenta.
- The placenta should be delivered by maternal effort alone.
- The placenta should deliver spontaneously within an hour following the birth.
- Blood loss cannot be estimated in the pool. Clots may be collected in a sieve and weighed. The midwife must make a clinical decision about the blood loss – as a general rule, if it is impossible to see the bottom of the pool due to the colour of the water, excessive blood loss may have occurred.
EBL SHOULD BE RECORDED AS MORE OR LESS THAN 500MLS.
- Placental check as per a land birth
Active management of the third stage
The woman should be asked to leave the pool prior to the administration of an oxytocic drug and delivery of the placenta. DO NOT attempt CCT in the water.
- Assist the woman to leave the pool
- 1 ampoule (10 i.u) of Syntocinon to be given IM with consent.
- Keep mother and baby warm; lie in a suitable, safe place to facilitate delivery of the placenta.
- Observe signs of placental separation. Apply controlled cord traction whilst guarding the uterus
- Active management should be complete within 15-30 minutes post birth. Contact a senior doctor if the placenta has not been delivered at this point.
- Placental check and EBL as per a land birth
Care following the birth
- Examination of the perineum should take place out of the pool.
- Excepting cases of profuse bleeding, suturing of perineal tears should be delayed for at least one hour following the birth to allow for water retention of the perineal tissues to dissipate.
EMERGENCIES IN THE WATER
Most emergency situations can be managed with the woman still in the pool.
Very rarely do low-risk women have to be helped from the pool in an emergency.
In all cases of emergencies in the water, prompt recognition of a deviation from the norm is paramount: summon rapid assistance on 2222 or 999 assistance in a home setting.
- Shoulder dystocia
- If the fetal head fails to restitute and the body is not expelled within the next strong contraction with maternal effort, stand the mother up out of the water immediately.
- Raise one leg up on the step of the pool (or the side of the pool if the woman is able to) If shoulders do not come with the next contraction help her promptly from the bath, lay her on a mat on the floor, summon emergency assistance 2222 immediately and start the emergency drill for shoulder dystocia.
- Baby requiring resuscitation
- Clamp and cut the cord immediately and remove from the water. Call for neonatal assistance on 2222 and commence newborn life support (NLS) drill
- If in a home setting, summon 999 assistance and utilise NLS equipment.
- Post partum haemorrhage (if EBL estimated >500mls)
- Clamp and cut the cord if the placenta is still in-situ.
- Give Syntometrine 1 ml and assist the women from the pool immediately.
- Active management of 3rd stage
- Summon assistance on 2222; utilise PPH trolley
- Call 999 if in a home setting
- Assess for transfer to Labour Ward or theatre for continuing management of postpartum haemorrhage
- Follow drill for major obstetric haemorrhage
- Snapped Cord
- Very occasionally, it has been noted that the cord may snap as the baby emerges
- Quickly clamp and cut the cord at both ends to ensure minimal blood loss
- Observe the infant closely for signs of distress
- Notify a paediatrician
- Commence NLS if required
- Emergency evacuation of pool in NBC or LW
Number of handlers required:
- Lead midwife to call for emergency assistance on 2222 immediately.
CLEANING THE POOL
Stringent infection control principles should be adhered to at all times.
- Before removing the plug, remove as much debris as possible using the sieve.
- Open the plug to remove contaminated water.
- Rinse the pool using the shower attachment.
- Mix 1 litre of Chlorclean solution using strength of 1 tablet of Chlorclean to 1 litre of water
- Using a disposable cloth and gloves use the solution to clean the pool, and the surfaces and steps around the pool.
- Rinse with cold water to remove the Chlorclean solution.
- Dry the pool.
- The plug should be closed when the pool is not in use.
- There should be no moisture at the bottom of the pool when not in use; it must be left dry to prevent bacteria forming.
Cleaning and disinfecting of equipment:
- Using hot, soapy water, wash the pool thermometer, mirror and any other re-usable equipment that has been used in the pool.
- Soak the equipment in the pool bucket provided for at least 30 minutes in a solution made of 1 Chlorclean tablets to 1 litres of water.
- Rinse and dry the equipment.
REFERENCES AND BIBLIOGRAPHY
- Alderice, F, Renfrew, M and Marchant, S (1995) Labour and birth in water in England and Wales. British Medical Journal. Vol 310; pp837
- Belbin, A. 1996 Power and choice in birthgiving: a case study British Journal of Midwifery Vol 4 No 5 pp264-267
- Brown, L. 1998 The tide has turned: an audit of waterbirth. British Journal of Midwifery
- Charles, C. (1998) Fetal hypothermia risk from warm water immersion. British Journal of Midwifery Vol 6 No3 pp 152-156
- Cluett, ER and Burns, E (2009) Immersion in water in labour and birth. Cochrane database of systematic reviews. Issue 2. J Wiley and Sons: Chichester.
- Forde, C et al 1999 Labour and delivery in the birthing pool. British Journal of Midwifery Vol 7 No 3 pp165-171
- Gilbert, RE and Tookey, PA (1999) Perinatal mortality and morbidity among babies delivered in water; surveillance study and post survey. British Medical Journal. Vol 319 (7208) ; pp 183-187
- Gordon, Y. 1996 Waterbirth: the safety issues in 1996 Waterbirth unplugged Books for Midwives Press pp135-142
- Hall, SM and Holloway, IM (1998) Staying in control; women’s experience of labour in water. Midwifery. Vol 14 (1) pp 30-6
- Johnson, P. 1996 Birth under water: to breathe or not to breathe. British Journal of Obstetrics and Gynaecology
- McLean, M.T. 2000 Lingering concerns about waterbirth. Midwifery Today Vol 1 N0 54 p 7
- Mills, M. S. and Stirrat, G. M. 1996 Water immersion and waterbirth. Current Obstetrics and Gynaecology
- Odent, M. 1998 Use of water during labour: updated recommendations. MIDIRS Vol 8 No 1 pp68-69
- Richmond, H (2003) Women’s experience of waterbirth. Practising Midwife Vol 6; pp 26-31
- Royal College of Midwives (2012) Evidence Based Guidelines for Midwifery-led care in labour. RCM: London
- Royal Collage of Obstetrics and Gynaecology / the Royal College of Midwives (2006) Joint statement no. 1; Immersion in water during labour and birth. RCOG: London
- Wickham, S (2005) The birth of water embolism. The Practising Midwife. Vol 8(11) pp37
PROCESS FOR MONITORING
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PROCEDURE FOR EMERGENCY POOL EVACUATION IN THE EVENT OF
1. Call for emergency help
2. Support the mother’s head above water
3. DO NOT empty the pool – water helps to float the woman out of the pool
4. Locate the sling net from the adjoining sluice room
5. Prepare a bed / trolley at pool height to receive the woman – remove the head of the bed if necessary and switch off electric supply
6. Prepare towels to receive the woman to keep warm and maintain temperature
7. Minimum 5 members of staff required
8. Work as a team. Float the sling under the woman covering the full length of body, arms inside the sling
10. Work as a team.
X1 staff at the woman’s head
X2 staff on either side of the net, feet supported
11. Work as a team.
12. On the count of 3, transfer from pool to bed using the sling net, with full support
13. Start CPR if required