Barbara Harper explores the effects of water temperature on mothers and babies.
Barbara Harper explores the effects of water temperature on mothers and babies.
A. Thoeni*, F. Ploner and N. Zech 2008
Department of Gynaecology and Obstetrics, District Hospital of Vipiteno, Northern-Italy
Objective: The potential for increased risks of infection is an important concern with water births.
We performed microbiological analyses on water samples taken from birthing pools before and after water births, and compared the rate of neonatal infection arising after water births with that arising after conventional delivery.
Materials and Methods:
In this prospective observational study beginning in 2001, water from the delivery pool was analyzed to determine the prevailing microorganisms.
Two water samples were taken at each delivery.
The first sample (sample A) was taken after the tub was filled with tap water; the second sample (sample B) was taken after the delivery.
The high rate of water contamination with Legionella pneumophila and Pseudomonas aeruginosa led us to install a filter system (Aquasafe –FilterR) into the supply hose for the birthing pool to reduce the water contamination.
This intervention significantly reduced the total microbial loading and there was no longer evidence of Legionella pneumophila.
Furthermore, we determined the rate of neonatal infections in infants delivered in water and compared it with those delivered conventionally out of the water.
Samples were obtained from 300 out of a total of 1,625 water deliveries, which took place between 2001 and 2007. Before the installation of a filter system, 29% of the A-samples showed bacterial growth with Legionella pneumophila,
22% with Pseudomonas aeruginosa, 18% with enterococci, 32% with coliforms, and 8% with Escherichia coli.
After the installation of the filter system, the water contamination decreased considerably:
– there were no further signs of Legionella bacteria, and Pseudomonas aeruginosa was found in only 3% and coliforms in 13% of the samples, respectively.
By comparing the microbiological composition of the B-samples before and after installation of the filter system, we concluded that the intervention did not influence the microbial loading of the water, which occurred during and as a result of
the whole delivery phase.
The microbiological loading of the water in the birthing pool after it was filled may have partly originated from the insufficient cleaning and disinfections of the birthing pool and after changing the cleaning records there was no longer any evidence of a significant microbial count (unpublished data).
Of the B-samples, 82% contained large amounts of coliforms, 64% contained Escherichia coli with concentrations of up to 105 CFU/100 mL, and 8-12% contained Pseudomonas aeruginosa.
Staphylococcus aureus and Candida spp were also
present in moderate amounts.
The rate of neonates treated with antibiotics for suspected infection on the basis of clinical symptoms (tachypnoea, skin color) or laboratory findings (CRP rise, leukocytosis) was 1.05% after water births (17 out of 1,625) compared with
1.75% (20 out of 1,139) after conventional delivery (p<0.05).
Based on our results and the literature, water birth is a valuable alternative to traditional delivery when certain criteria are met and risk factors are excluded.
During water birth, faeces are discharged into the pool and the water is
contaminated with a variety of microorganisms.
However, contamination of the water with such microorganisms seems not to translate into an increased risk of neonatal infection.
Zainab Kassim, clinical research fellow in neonatology1, Maria Sellars, consultant in radiology2, Anne Greenough, professor of neonatology and clinical respiratory physiology1
1 Department of Child Health, Guy’s, King’s and St Thomas’ School of Medicine, King’s College Hospital, London SE5 9RS, 2 Department of Radiology, King’s College Hospital, London
In 1992 the House of Commons Select Health Committee’s report on maternity services recommended that all hospitals should provide women with the “option of a birthing pool where this is practicable.
“1 A subsequent surveillance study of all NHS maternity units between 1994 and 1996 found that 0.6% of all deliveries in England and Wales occurred in water.2
Rawal and colleagues have suggested that water births have become popular among mothers and midwives because the buoyancy and warmth of the water promotes natural labour while providing a non-invasive safe and effective form of pain management.3
Practitioners and parents should remember, however, that birthing pools pose potential risks for the baby. We report on a newborn baby who developed respiratory distress due to aspiration after an underwater birth.
A full term male infant weighing 3150 g was born in the birthing pool of the labour ward of our hospital. His mother was a 34 year old, healthy primigravida who had had an uneventful pregnancy.
She had gone into spontaneous labour at 40 weeks’ gestation and had had no maternal fever during labour; at delivery the membranes had been ruptured for less than 18 hours. The baby was born underwater.
He required no resuscitation but, when reviewed at one hour, was grunting. As the grunting persisted, he was admitted to the neonatal intensive care unit at 3 hours of age. He had no fever but was tachypnoeic and had intercostal recession and nasal flaring.
He needed supplementary oxygen to maintain his oxygen saturation level at 92%; his need for supplementary oxygen persisted for nine hours. He was screened for infection and started on antibiotics (benzylpenicillin and gentamicin).
In view of his respiratory distress, which persisted for 48 hours, he was designated “nil by mouth” and fluid was administered intravenously until he had recovered. Chest radiography soon after admission showed widespread changes consistent with aspiration of the birthing pool water (figure).
Further radiography, on day 3, showed resolution of the abnormalities, and the infection screen was negative. The infant made a full recovery and, when seen as an outpatient at age 3 months, was free of symptoms.
Some researchers have suggested that “babies can only drown when submerged, only if they are already severely compromised and literally at their `last gasp,’ as water simulates vagal inspiration receptors causing glottic closure.”4
In lambs, however, inhibitory mechanisms that prevent breathing until the lamb is in contact with cold air can be overridden by sustained hypoxia.5
Likewise, in a birthing pool, some babies with unrecognised hypoxia may gasp underwater. Indeed, the 1994 to 1996 survey cited two reports of water aspiration,2 and similar cases have been documented in the literature.6-8
Our case report emphasises the adverse effects of aspiration of water in birthing pools. Although such events seem uncommon, this may be the result of under-reporting.
Respiratory distress immediately after birth is common and has various aetiologies. Thus, unless a careful history is taken, the cause the respiratory distress may be misdiagnosed.9
We are confident that the case we report was due to aspiration of water as the infant developed symptoms soon after birth, with resolution by 48 hours.
In addition, there were no risk factors for infection or indeed any bacterial infection identified. Infection after water birth has been described.10-12
The baby in our case report was delivered after spontaneous labour at term, making transient tachypnoea of the newborn unlikely; indeed, the chest radiograph was consistent not with that diagnosis but with aspiration.
A systemic review of randomised trials has shown that immersion during labour is associated with significant reductions in the use of epidural, spinal, or paracervical analgesia and in women’s reports of pain, but highlighted there were insufficient data to determine the outcome from randomised trials of birth in water for women or their infants.13
In addition to water aspiration and subsequent pulmonary oedema,8 however, other adverse neonatal outcomes after water birth have been reported; these include water intoxication, hyponatraemia, hypoxic ischaemic encephalopathy, cord rupture with neonatal haemorrhage, and pneumonia.12 14
Women who have water births are usually considered to be “low risk,” and so they and their infants should have an excellent prognosis. Our case report and review of the literature confirm that water birth has risks for the newborn.
Practitioners and parents need to be aware of these potential risks so that mothers can make a fully informed decision about place of delivery.
Water birth can be associated with adverse effects in the newborn
Contributors: ZKand AG collected the clinical data, and MS col- lected the radiographic data. All authors contributed to writing the paper, and AG is the guarantor.
Funding: No special funding. Competing interests: None declared.
(Accepted 16 March 2005)
Underwater birth and neonatal respiratory distress: Case report does not constitute reliable evidence
Elizabeth Cluett, Rona McCandlish, Ethel Burns, and Cheryl Nikodem
BMJ 2005 330: 1447-1448. [Extract] [Full Text]
Underwater birth poses risks for the baby
BMJ 2005 330: 0. [Full Text]
Perinatal mortality and morbidity among babies delivered in water: surveillance study and postal survey
Ruth E Gilbert and Pat A Tookey
BMJ 1999 319: 483-487. [Abstract] [Full Text] Author’s reply
BMJ 1995 310: 1602. [Extract] [Full Text] Water birth and infection in babies
J Rawal, A Shah, F Stirk, and S Mehtar BMJ 1994 309: 511. [Full Text]
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The New Zealand College of Midwives (Inc) supports immersion of women in warm water during labour as a method of pain management.
There is no evidence that remaining in water for the birth of the baby leads to adverse outcomes for the mother or baby where the labour has been within normal parameters.
Water birth means where a baby is born fully submerged into water.
• Evidence supports immersion in warm water as an effective form of pain relief that reduces the use of narcotics.
• There is no evidence to suggest that immersion in water during labour or birth in water leads to any detrimental effects for either the mother or her baby.
• Evidence that immersion in water during labour reduces the length of active labour is inconclusive.
• Evidence that birth in water reduces perineal trauma or blood loss is inconclusive.
Midwives offering water immersion for labour and for birth are responsible for ensuring the information given to women is accurate and up to date.
The following guidelines are recommended:
• There are no adverse factors noted in foetal or maternal wellbeing during labour.
• Baseline assessments of both maternal and baby wellbeing should be done prior to entering the bath/pool and assessments continued throughout the time in water as for any normal labour.
• Vaginal examinations can be performed with the woman in water.
• Pethidine should not be given to women labouring in water.
• The water temperature should be kept as cool as the woman finds comfortable during the first stage of labour (around 35oC) and increased to no more than 37oC for the baby’s birth.
• If maternal temperature rises more than 1oC above the baseline temperature then the water should be cooled or the woman encouraged to leave the bath/pool. Women need to be aware of this in advance.
• Water temperature should be recorded as the woman enters the bath/pool and regularly during the time she remains in the pool.
• Careful documentation should be kept of maternal and water temperatures, FHR and the approximate surface area of the woman’s body submerged.
• The cord should not be clamped and cut until after the birth of the baby’s body.
• The baby should be brought to the surface immediately, with the head facing down to assist the drainage of water from the baby’s mouth and nose.
• The baby’s body can remain in the water to maintain warmth, unless the baby’s condition dictates otherwise. (Note: babies born in water may take slightly longer to establish respirations than those born into air. Maintain close observation of colour, heart rate and respirations.)
• Third stage should be managed physiologically as for any other low risk birth. If oxytocin is required or third stage is prolonged the woman is assisted to leave the bath/pool.
• Midwives must ensure that baths and pipes are thoroughly cleaned after use.
Title: Labour and delivery in the birthing pool
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Title: Warm tub bathing during labour: maternal and neonatal effects
Authors: Ohlsson, G, Buchave, P, Leandersson, U, Nordstrom, L, Rydhstrom, H, and Sjolin, I
Source: Acta Obstetricia et Gynecologica Scandinavica, Vol 80, pp 311 – 314, 2001
Title: Immersion in water in the first stage of labour: a randomised controlled trial
Authors: Eckert, K, Turnbull, D, and MacLennan, A
Source: Birth, Volume 28, No 2, pp 84–93, June 2001
Title: Immersion in water during first stage of labour
Author: Homer, C
Source: Letter to the editor, Birth, Vol. 29, No 1, March, 2002
Title: Waterbirths: a comparative study. A prospective study on more than 2000 waterbirths Authors: Geissbuhler, V and Eberhard, J
Source: Foetal Diagnosis Therapy, Vol. 15, pp. 291 – 300, 2000
Title: Immersion in water in pregnancy, labour and birth Author: Nikodem, VC
Source: Cochrane Database Systematic Review, 2000
Title: Perinatal mortality and morbidity among babies delivered in water: surveillance study and postal survey
Authors: Gilbert, R and Tookey, P
Source: British Medical Journal, 319 (7208), pp. 483 – 487, 1999
Title: Birth under water – to breathe or not to breath
Author: Johnson, P
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Title: Labour and birth in water: temperature of pool is important
Authors: Deans, AC and Steer, PJ
Source: British Medical Journal. 311:390-391, 1995
Title: Waterbirth – An attitude to care
Author: Garland, D
Source: Books for Midwives, 1995. Chesire
Title: Foetal hypothermia risk from warm water immersion
Author: Charles, C
Source: British Journal of Midwifery
The purpose of New Zealand College of Midwives Consensus Statements is to provide women, midwives and the maternity services with the profession’s position on any given situation.
The guidelines are designed to educate and support best practice.
All position statements are regularly reviewed and updated in line with evidence-based practice.
Zanetti-Dällenbach, Rosanna1; Lapaire, Olav; Maertens, Anne; Holzgreve, Wolfgang; Hösli, Irene (2006) Archives of Gynecology and Obstetrics, Volume 274, Number 6, October 2006 , pp. 355-365(11)
To prospectively assess the effect of water birth on maternal and fetal outcomes in a selected low-risk collective of a tertiary obstetrical unit.
In this prospective observational study, 513 patients of a low-risk collective, who requested a water birth, were studied during the years 1998-2002. Primary outcome measurements included the maternal and fetal parameters.
Secondary outcome measurements comprised data on the incidence of water births in an interested, low- risk population in an academic hospital.
All groups were similar in terms of demographic and obstetric data. Significant differences were observed in maternal outcome parameters, which included the use of analgesia/anesthesia during labor, the duration of first and second stages of labor, perineal tears and episiotomy rate.
No differences were seen in all observed fetal outcome parameters including APGAR scores, arterial and venous pH, admission rate to neonatal intensive care unit and infection rate.
Water birth is a valuable and promising alternative to traditional delivery methods. The maternal and fetal outcomes were similar to traditional land births. However, currently there still exist some deficits in the scientific evaluation of its safety.
Therefore, the selection of a low-risk collective is essential to minimize the risks with the addition of strictly maintained guidelines and continuous intrapartum observation and fetal monitoring.
Based on our results and the literature, water births are justifiable when certain criteria are met and risk factors are excluded.
Nadine Massiah MBBS
Obstetrics and Gynaecology Department
Furness General Hospital
Barrow in Furness UK
Vincent Bamigboye MRCOG
Obstetrics and Gynaecology Department
Furness General Hospital
Barrow in Furness UK
Citation: N. Massiah & V. Bamigboye : Shoulder dystocia at water birth . The Internet Journal of Gynecology and Obstetrics. 2008 Volume 9 Number 1
Health professionals providing obstetric care should be familiar with guidelines for shoulder dystocia. Regular drills are fundamental to the improvement of team work, enhancing communication skills and essential for good outcomes5.
Obstetric birthing simulators should be considered since they significantly improve competence in the management of shoulder dystocia6,7.
Learning and teaching are continuous processes in our practice. Optimal training is required to minimize morbidity and mortality of this obstetric complication.
A 33 year old, para 1 lady presented in active labour at 40 weeks gestation. The abdominal findings were fundal height 39 cm, longitudinal lie and cephalic presentation.
Vaginal examination revealed cervical dilatation of 5 cm, occipito-anterior position of the foetal head at station minus two. The membranes were intact.
The booking investigations, dating and anomaly scans were found to be normal. The current pregnancy was uncomplicated. The first pregnancy and vaginal delivery were uneventful.
The pool was requested for labour and delivery. The labour progressed well to full dilatation. There was good descent of the head with active pushing. After delivery of the head, the shoulders were impacted. Mc Robert’s manoeuvre and suprapubic pressure were attempted without success.
The patient was moved from the birthing pool to the bed. Mc Robert’s manoeuvre, suprapubic pressure and downward traction of the head led to delivery of the anterior shoulder followed by the remainder of the body.
The time interval between the delivery of head and body was 3 minutes. The estimated blood loss was 350 mls. The neonate had a birth weight of 4200g with an Apgar score of 8, 9 and 10. Paediatric examination of the neonate was normal.
The incidence of shoulder dystocia at water birth is 0.16%1. This case highlights that it is vital to be prepared for emergencies even with low risk women. They may occur in unfamiliar situations. Since the patient was wet, her safety whilst being moved to the bed was of great concern.
This was done carefully but quickly. It is estimated that the umbilical cord pH falls by 0.04 unit/min after delivery of the head2. A delay in delivery of the shoulders may result in cerebral hypoxia, cerebral palsy or death.
Forty seven percent of deaths from shoulder dystocia were within 5 minutes of delivery of the head3. The principles of management were widening of the pelvic diameters and repositioning the foetal shoulders into the oblique pelvic diameter to facilitate delivery4.
Health professionals providing obstetric care should be familiar with guidelines for shoulder dystocia.
Regular drills are fundamental to the improvement of team work, enhancing communication skills and essential for good outcomes5.
Obstetric birthing simulators should be considered since they significantly improve competence in the management of shoulder dystocia6,7.
Learning and teaching are continuous processes in our practice. Optimal training is required to minimize morbidity and mortality of this obstetric complication.
1. Thöni A, Zech N, Ploner F. Giving birth in the water: experience after 1,825 water deliveries. Retrospective descriptive comparison of water birth and traditional delivery methods. Gynäkologisch-geburtshilfliche Rundschau 2007; 47(2):76-80.
2. Wood C, Ng KH, Hounslow D, Benning H. Time – an important variable in normal delivery. Journal of obstetrics and gynaecology of the British Commonwealth 1973; 80(4):295-300.
3. Confidential Enquiries into Stillbirths and Deaths in Infancy. Fifth Annual Report. London: Maternal and Child Health Research Consortium, 1998. (s)
4. Draycott TJ, Fox R, Montague IA. Shoulder dystocia. RCOG Guideline No. 42. London:RCOG 2005.
5. Sorensen SS. Emergency drills in obstetrics: reducing risk of perinatal death or permanent injury. JONAS Healthcare Law Ethics and Regulation 2007; 9(1):9-16.
6. Deering S, Poggi S, Macedonia C, Gherman R, Satin AJ. Improving resident competency in the management of shoulder dystocia with simulation training. Obstetrics and Gynecology 2004;103(6):1224-8
7. Crofts JF, Bartlett C, Ellis D, Hunt LP, Fox R, Draycott TJ. Training for shoulder dystocia: a trial of simulation using low-fidelity and high-fidelity mannequins. Obstetrics and Gynecology 2006; 108(6):1477-85.
Since the early 1980s use of immersion in water during labour and birth has been increasingly promoted to enable women to relax, help them cope with pain, and maximise their feelings of control and satisfaction1-4.
In 1992 the House of Commons Health Committee recommended all hospitals provide the option of a birthing pool where practicable5. Currently few women give birth in water but the option of immersion or showering during the first stage of labour is commonly available.6-8
Although problems have arise which have been attributed to water use, the results of the most formal evaluations have not clearly associated water use with harmful outcomes for mother or baby 3,9-13.
The lack of robust evidence of harm or benefit means that childbearing women and health practitioners alike are subject to conflicting opinion about the usefulness and safest of water, particularly for birth.
However, a recent observational study over a nine year period concluded that ‘waterbirth was associated with low risks where obstetric guidelines were followed’16.
At present in the UK there is no reliable measurement of the rate of birth in water. A national survey of maternity units in the UK in 2002 found that 63% (216/342) had a birthing pool8; 67% (228/342) reported having at least one midwife trained to provide support for women giving birth in water and 36% (121/342) said that at least half of the midwives working in their unit were trained to support birth in water.
How is water used during labour?
Water use ranges from informal, for example when a woman in early labour decides to get into her bath at home before going to hospital, to formal use in a specially designed birthing pool. Informal use in a domestic bath or shower is often initiated by a woman herself to help her cope at home before her labour is well established.
Formal use implies either that a woman has actively chosen to use water as part of her plan for labour and/or childbirth or that a health professional, usually a midwife, has suggested use during established labour.
Why water use is promoted
Use of immersion in water during childbirth has largely been driven by pregnant and birthing women17 and supported by midwives. During the first stage of labour it is advocated to shorten labour and help a woman relax and cope with contractions, feel more in control, and to reduce intervention by health professionals3,18-21.
During the second stage, proponents use it to allow perineal tissues to stretch spontaneously, birth to occur with minimum intervention, and to provide the baby with a gentler transition into extra-uterine life. Expectant management of the third stage is likely if a woman is in water.
Limitations on water use
Many health professionals consider that water use during the first stage of labour in uncomplicated pregnancy is unlikely to harm the mother or baby22,23, whilst others have concerns about water use at any point in labour14.
Local clinical guidelines may restrict water use to women considered at ‘low’ obstetric risk7, and other aspects of care may be prescribed, for example when and how to monitor the temperature of the water, the degree of cervical dilatation at which to begin its use24, and whether the immersion is considered safe for all stages of labour6,25.
Problems associated with possible risk of infection or cross infection caused by amniotic fluid, blood, and faeces have been described26-28 and some hospitals have restricted use of birthing pools to women who have tested HIV negative during pregnancy29.
However, at a multi-disciplinary consensus meeting held in London in 1996, it was agreed that mandatory HIV testing for prospective users of birthing pools could be an extreme reaction to the perceived risks and that high standards of pool hygiene would be an appropriate way forward30. Local infection control guidelines should cover the use of water pools25,31 and procedures to minimise risk of cross infection13, 32.
It has been suggested that high water temperature can cause serious changes in feto-maternal haemodynamic regulation and fetal thermoregulation33. It has been reported that fetal tachycardia can be reduced by cooling the water34 and most providers and clinical guidelines specify a temperature range within which the water should be maintained during the first and second stage of labour7,35.
The prospect of a woman giving birth in water can cause anxiety about how to deal with unexpected emergencies such as shoulder dystocia, the need to avoid the baby inhaling water, or being unaware that the umbilical cord has been severed11.
Despite the fact that it denies women choice about birth, one response has been to limit water use to first stage only6. Development of agreed clinical protocols to deal with unexpected complications25 and providing training which allows3 staff to achieve relevant competencies is key to enabling real choice for women about use of water.
There are theoretical risks of increased blood loss, retained placenta, or water embolism, and professional advice is often to conduct the third stage out of water25.
Because water adds to the difficulty of estimating blood loss accurately, it has been proposed that blood loss would be more appropriately estimated as being either more or less than 500ml36 and that the overall physical condition of the woman should be used as the most important indicator to assess the impact of any bleeding37.
In summary, although not universally accepted, first stage water use is less controversial than immersion for the second or third stage of labour22,23,38.
The research evidence
The effects of water use during the first stage of labour on maternal and fetal outcomes have been evaluated in several randomised controlled trials4,9,10,12,13,39 with sample sizes ranging from 60 to 123934.
The use of water has been shown to reduce the rate of augmentation40; however, no trial has been large enough to measure the effect of water use on important neonatal outcomes such as perinatal death or other serious neonatal or maternal morbidity.
In addition, there has often been significant cross-over between study groups4,12, reducing the likelihood of identifying clear differences between women allocated to water use and those not.
A systematic review of eight trials41 indicated a statistically significant reduction in the use of pain relief with no such significant difference in the rate of operative deliveries or in neonatal outcomes.
It concluded that while the use of water in the first stage of labour can be of benefit to some women, there is no evidence at present to support or not support a woman’s choice to give birth in water.
Retrospective comparison has been made of women who have used water with those who have not42,43.
However, there are considerable difficulties in interpreting such studies because of the possibility that the results are inherently biased.
In the same way, findings of cohort studies which suggest benefit for water use in terms of pain relief and increased rate of cervical dilatation44-47, or those which indicate differences in rates of maternal and neonatal infection48-50, are also open to criticism.
A recent study16 compared neonatal and maternal morbidity and mortality for spontaneous singleton births that took place in water or on land.
This was an observational study over a nine year period and data were obtained through standardised questionnaires for 9,518 births, of which 3,617 were waterbirths and 5,901 landbirths.
Statistically significant differences were identified between the two groups; women who gave birth using water were less likely to suffer serious perineal trauma, use no analgesia and have a lower blood loss than women in the landbirth group.
Maternal and neonatal infection rates were the same for both groups, but more landbirth babies had neonatal complications requiring transfer to an external NICU.
During the study, there were neither maternal nor neonatal deaths related to spontaneous labor.
The authors acknowledge the potential bias that could arise from the self-selection issue but argue that this is well accounted for in the analysis.They conclude that waterbirths are associated with low risks for both mother and child when obstetrical guidelines are followed.
Another study51 based in a centre for low risk women was a retrospective case review over a five year period of 1355 births in water.
When compared with land births over a corresponding period, women who gave birth in water had significantly fewer episiotomies with no evidence of a corresponding rise in lacerations, a reduction in the length of the first stage of labour, no increase in the risk of acquired infection or aspiration pneumonia and considerably lower levels of analgesia use.
Neonatal condition assessed by arterial cord blood pH, base excess and birth weight showed no differences.The authors conclude that this represents a realistic option for women at low risk of complications.
Many reports about water use are case series1,20,52-62 and focus on perceived benefits of water use for the mother, her baby and birth attendant.
These include shorter labour52, less use of pharmacological analgesics46,53, less intervention by care givers19, lower rate of perineal trauma60-62, and increased satisfaction with the experience of labour and birth54.
By contrast, some case reports have highlighted serious problems such as fetal overheating33,34, neonatal sepsis28, near drowning63 or death64.
Overall, reviews of the evidence21,23,65,66 conclude that appropriately large-scale research is still required to evaluate rigorously the physiological effects13, clinical outcomes, and economic impact of water use.
What we don’t know
The current evidence about water use remains quite heavily dependent on case series and comparison studies that include varying sized samples.
Therefore, reliable evidence about efficacy and effectiveness is still equivocal67.
Implications for maternity
Water use during the first stage of labour is offered by the majority of maternity care provider units in the UK and most offer support for water birth8.
Introduction of, and sustained suppor t for, water use may have considerable implications for service governance68.
However, not all costs fall to providers of care; a substantial cost burden is likely to be borne by labouring women themselves during informal use in domestic baths and showers or by hiring specially designed pools for use in their home or in a maternity unit.
Most maternity units have installed a water pool for use in labour8 and although installation and maintenance of a specially designed pool in a maternity unit involves obvious financial cost, this may be offset if there is a reduction in analgesia and anaesthetic use44.
There is evidence that formal water use means that at least one midwife will be in constant attendance during the first stage of labour and that at least two will be in attendance for birth7.
This level of staffing may be difficult to sustain and may have implications for equity of care for women who do not use water22.
Clear strategies for the training, preparation and support of staff who offer use of water during labour are recognised as essential7,25,31,37,44.
Key components of these include clarification of the roles of different maternity health professionals, multi-disciplinary development of local protocols, development of guidelines for clinical practice, and short-term secondment of midwives to learn alongside practitioners skilled and experienced in water use.
Implications for practice
Women may choose to use immersion in water during labour and/or birth. Midwives and other maternity care workers should therefore be knowledgeable about the evidence in terms of potential advantages and disadvantages.
Given the current quality of reliable evidence, effective practice is likely to be informed and influenced substantially by shared experience and personal observation.
Disproportionate weight may therefore be placed on perceived disadvantages or advantages and credibility given to outcomes which may not be associated causally with water use.
Practitioners should be alert to the evolving evidence base which underpins the use of water.
Reproduced from Midirs 2005, last revised Jan 2005, review date Jan 2007. Informed Choice is supported by the Royal College of Midwives and the National Childbirth Trust.
Barbara Harper 2006
The aim of this guideline is to provide a review of information on labor and birth in water and to suggest possible strategies to minimize the potential hazards to mothers and infants.
It can also be used to promote the maternal and infant benefits, which may arise from choosing this type of birth experience, but are not easily quantifiable.
It is written with the belief that clinically sound, evidence based guidelines improve quality of care.
These recommendations are not intended to dictate an exclusive course of management or treatment.
They must be evaluated with reference to individual client’s needs, resources and limitations unique to the place of birth and variations in client choices.
The therapeutic properties of warm water immersion have been known for centuries. Baths, showers and whirlpools have been used for comfort during labor for many years. Over the past two decades the use of warm water immersion for the birth of the baby has aroused interest in many countries and an increase in the number of women requesting this option for both hospital and out-of-hospital births is occurring.
Waterbirth International has reviewed the best available evidence and offers this guideline to assist midwives and women in their decision making process around the use of water immersion for labor and birth. The body of evidence is small but growing.
Maternal and neonatal outcomes after water immersion for labor and birth have been assessed in two large surveys over a four year period in England and Wales (Alderdice, Renfrew & Marchant, 1995; Gilbert & Tookey, 1999) Researchers reviewed 4693 and 4032 births, respectively, where water immersion was used and found no difference in outcomes for women and their newborns compared to a cohort group of low risk women who did not use water.
The perinatal mortality rate for these births was comparable to other low risk births in the UK. (Gilbert and Tookey 1999). This study tried to estimate mortality and morbidity rates for babies delivered in water.
The data collected was compared to other sources of data providing similar estimates for babies delivered conventionally to low-risk women. They examined adverse outcomes, which were reported over a two-year period between 1994 and 1996 from approximately 4,000 births in water. 1500 consultant pediatricians were surveyed and asked to report any cases of baby deaths associated with waterbirth. None of the five perinatal deaths recorded among the waterbirths was attributable to delivery in water.
Admissions to special care baby units were slightly lower for the water-born babies than admissions for other low-risk babies. This was a landmark study in providing significant reassurance about the safety of waterbirth.
Other researchers (Burns 2001; Lenstrup et al, 1987; Rush et al,1996; & Waldenstrom et al, 1992) have made similar outcome reports. A recent Canadian randomized control trial reported women experienced less pain after water immersion than their non-immersion counterparts and over 80% of the water immersion group said they would use the tub in subsequent labors (Rush et al, 1996).
There have been a few highly controversial reports in the literature, especially in the journal Pediatrics on the negative effects of water immersion for babies. “Water Birth: a near drowning experience (Nuygen et al, 2002) suggests that every case of waterbirth should be evaluated as a possible fresh water drowning. The authors’ conclusions that the use of water for labor and birth may contribute to adverse outcomes should be viewed with considerable caution.
There are several methodological problems with this case study and these results are not congruent with the findings of many large trials. It is clear more research is needed into this form of care. But opinion pieces should be viewed at just that, opinion and not referred to as scientific or medical evaluation of the evidence.
In the absence of a substantial body of evidence on the use of warm water immersion for labor and birth, the potential advantages and disadvantages, which follow, are primarily derived from experience. This guideline will be updated as more evidence becomes available.
Water immersion for labor and birth should be available to all clients who request it, who have been screened and who have discussed the risks and benefits with their care provider. Some practices may choose to use a standard informed consent form for the use of warm water immersion.
Water immersion must be defined at providing a depth of water which enables the mother to sit in water that covers her belly completely and comes up to her breast level or kneel in water on her haunches which comes up to just below her breast level.
Any amount of water less than this does not constitute true immersion and will not create the buoyancy effect and produce the chemical and hormonal changes which enhance a more rapid labor. After an initial immersion of approximately thirty minutes the body responds by releasing more oxytocin, but only if the body experiences deep immersion, leading to buoyancy.
It has been reported in the literature that labor slows down or stops if the woman enters the bath too soon. Guidelines were established to prevent a woman from entering the bath before the start of active labor, by definition: established labor pattern, dilation of the cervix to 4cm or greater and the need to concentrate during the contraction.
We argue that observation has led us to believe that a woman should be given the opportunity to use immersion as soon as her body and her brain have the desire to bathe. Women have been observed in very early labor relaxing, letting go of fear and progressing quickly to an active and pushing phase of their labor.
Using the water effectively often requires a “trial of water,” to see how the mother will respond. It has been noted with the advent of underwater continuous fetal monitoring that contraction patterns once thought to space out and become less frequent were in fact exactly the same in or out of the water. The mother’s response to those contractions in the water was vastly different from the response on the bed, thus making everyone believe that they were less intense.
The chemical and hormonal effects of immersion take effect after no less than twenty minutes and peak around ninety minutes. It is therefore suggested that a change of environment, such as getting out and walking be recommended after about two hours of initial immersion. The midwife can make an evaluation of the mother’s condition at that time.
Getting back in the water after thirty minutes will reactivate the chemical and hormonal process, including an sudden and often marked increase in oxytocin.
Dianne Garland, registered midwife, lead waterbirth researcher in England and the author of, ” Waterbirth: An Attitude to Care,” says the following:
” Just as labors can be slower or stop out of water so is true of water. Changes to the woman’s body are normal in labor and each of us will tolerate different lengths of first and second stage. Just as we all deal with different amounts of fatigue and stress, so each woman is individual and should be treated as such in labor.
The point of this with water labor and waterbirth is that as each woman is an individual, so her labor should be cared for, within the normal parameters set by ourselves as autonomous practitioners. Or within the maternity units where we work. Fundamental changes to normal practice may need to be made in units where active management of labor prevails.”
There are no contraindications to labor in water, as evaluated by the literature and from experience. Immersion is a client/provider decision. Birth in water comes with a few “ABSOLUTE” contraindications and a few “CONTROVERSIAL” contraindications.
The presence of meconium should be evaluated with fetal well-being and taken by itself as a reason to ask the mother to leave the water. Meconium washes off the baby in the water. Baby can be suctioned as soon as it has been brought to the surface of the water. Some practices are now only limiting thick meconium cases.
Evidence shows that HIV virus is susceptible to the warm water and cannot live in that environment. Proper cleaning of all equipment after the birth needs to be carried out. Hepatitis should be the discretion of the attending medical caregiver.
There is absolutely no evidence that GBS positive cases should be asked to leave the water. Most hospitals allow IV antibiotic administration while in the water.
Some providers will cover the lesion, especially if it has peaked and is sloughing off. Others will require a cesarean. Some feel it is safer to deliver in the water due to the dilution effect of the water.
In the H. Surreys Hospital in Ostend, Belgium, frank breech is an indication for a waterbirth. Their vast experience has led them to believe that the absence of gravity, the warm water and the buoyancy create the perfect environment for a hands free breech birth. Labor in water for both breech and multiples is well documented and recommended. This should be a client/provider decision.
This is usually considered an obstetric or midwifery emergency by most. Current protocols in most hospitals require the mother who is anticipating a large baby to leave the water. There is mounting evidence that providers find it is easier to assist a shoulder dystocia in the water. It is believed that tight shoulders happen more often because of mom or caregiver trying to push before the baby fully rotates. Better to wait a few contractions, with the head hanging in the water and allow baby to rotate. Because position changes in water are so much easier than dry land, a quick switch to hands and knees or even standing up with one foot on the edge of the pool helps to maneuver baby out. (research indicates that you can’t predict shoulder dystocia)
As the controversy over vaginal birth after previous cesarean section continues, it has been noted that mothers who labor for subsequent births have a much higher success rate in giving birth vaginally. Some hospitals refuse to allow women into the water because they don’t provide waterproof continuous fetal monitoring.
A few hospitals will allow a mother into the water after receiving an intrathecal Monitoring of the baby is suggested as continuous, but some hospitals allow intermittent monitoring.
Many hospital practices will now allow mothers whose labors are initiated by Misoprostal or Pitocin to get in the pool as soon as a labor pattern is established.
Some even allow mothers with a Pitocin drip to labor in water, as long as fetal heart rate assessment can be monitored with continuous underwater equipment.
Under no circumstances should the cord be clamped or cut under the water. Babies can be delivered through the cord and ‘unwound’ under the water. Be cautious of cord snapping.
Some providers will not allow women to birth in water that is lower than body temperature due to the possibility that the baby will attempt to inhale under the water from a change in temperature. There is no evidence that supports this theory, in fact there is more evidence that now shows that lower water temperatures increase the baby’s muscular activity and awareness.
Water babies are slow to start breathing due to the delay in stimulation of the trigeminal nerve receptors in the face and around the nose and mouth. You must consider the birth of the baby from the time it leaves the water, not from the delivery of the baby into the water. German midwife, Cornelia Enning, states that babies are more vigorous at a temperature around 92-95 degrees Fahrenheit. If the mother is comfortable in the water, the temperature is OK for baby with only one restrictive parameter – NEVER higher than 100 degrees Fahrenheit.
There is no reason not to allow the birth of the placenta in water. Objections include inability to judge blood loss, possible water embolism and inability to contain all the by products of conception in one place. Evidence now shows that delivery of the placenta is safe, blood loss can be estimated by color evaluation and determination of where the bleeding is arising and there is absolutely no scientific basis for worry over water embolism. Placenta and pieces can be placed in a floating bowl in the water without difficulty. Cutting and clamping of the cord is not recommended with the delivery of the placenta in the water.
Alderdice, R; Renfrew, M; & Marchant, S (1995) Labor and birth in water in England and Wales: Survey report. British Journal of Midwifery, 3. p 375 – 382.
Balaskas, J (2004) The Water Birth Book. London: Thorsons.
Beake, S. (1999) Water birth: a literature review. MIDIRS Midwifery Digest Vol 9 pp 473-477
Burns, E. (2001) Waterbirth, MIDIRS Midwifery Digest, Supplement 2, S10 – S13.
Burns, E & Kitzinger, S (2000) Midwifery Guidelines for Use of Water in Labor, Oxford Brookes University: Oxford.
Eckert, K; Turnbull, D; MacLennan, A. (2001) Immersion in water in the first stage of labor; A randomized controlled trial. Birth, 28 (2) p 84-93.
Enkin, Keirse, Neilson, Crowther, Duley, Hodnett and Hofmeyr (Eds) (2000) Control of Pain in Labour, in A Guide to Effective Care in Pregnancy and Childbirth Third Edition, Oxford University Press: Oxford.
Enning, C. (2003). Waterbirth Midwifery: A training book. Hippokrates, Stuttgart, Germany
Eriksson, M. Mattsson, L. Ladfors, L (1997 Sept) Early or late bath during the first stage of labour: a randomised study of 200 women. Midwifery, vol. 13 No 3 pp. 146-148
Garland, D., Jones, K. (June, 1997). Waterbirth: updaing the evidence. British Journal of Midwifery Vol 5. No 6,368-373
Garland, D. (Dec. 2002). Collaborative Waterbirth audit – “Supporting Practice with audit” MIDIRS Midwifery Digest, Vol 12, No 4, Dec 2002, pp 508-511
Garland, D., Crook, S. (March 2004) Is the use of water in labour an option for women following a previous LSCS. MIDIRS Midwifery Digest Vol 14, No 1 pp 63-67
Geissbuehler, V., Eberhard, J., (2000) Waterbirths: A comparative study, a prospective study on more than 2000 waterbirths. Fetal Diagnosis and Therapy Sept-Oct; 15(5):291-300
Geissbuehler, V., Eberhard, J., Lebrecht, A., (2002) Waterbirth: Water temperature and bathing time – mother knows best! Journal of Perinatal Medicine 30(2002) 371-378
Gilbert RE & Tookey PA (1999) Perinatal mortality and morbidity among babies delivered in water: Surveillance study and postal survey. British Medical Journal, 319(7208) p483-487.
Harper, B (Summer 2000) Waterbirth Basics: from newborn breathing to hospital protocols. Midwifery Today, 54: 9-15, 68
Harper, B (Dec 2002) Taking the plunge: reevaluating water temperature. MIDIRS Midwifery Digest, Vol 12, No 4, Dec 2002, pp 506-508
Johnson, Paul. (1996). Birth under water-—to breathe or not to breathe. British Journal of Obstetrics and Gynaecology, 103: 202-208.
Lenstrup, C., Schantz, A., Berget, A., Feder, A., Roseno, H. (1987) Warm tub bath during delivery. Acta Obstetrical Gynecology Scandinavia, 66, 709-12.
Mackey, M. (2001), Use of Water in Labor and Birth, Clinical Obstetrics and Gynecology, Vol 44, No 4, pp 733-749
Nikodem, VC Immersion in water in pregnancy, labour and birth. (Cochrane Review). In the Cochrane Library, issue 4, 2002. Oxford: Update Software
Odent, M (1998 March) Use of water during labour – updated recommendations MIDIRS Midwifery Digest, Vol 8, No 1 pp 68-69
Rush, J, Burlock, S. Lambert K (1996) The effect of whirlpool baths in labour: A randomized controlled trial. Birth, 23, p. 136-143.
Waldenstrom U & Nilsson C. (1992) Warm tub bath after spontaneous rupture of the membranes. Birth, 19 p 57-62
Waterbirth International (2004) unpublished Waterbirth Parent Survey, a retrospective analysis of over 3000 births in water.
Enthusiasts suggest that labouring in water and waterbirth increase maternal relaxation, reduce analgesia requirements and promote a midwifery model of care. Sceptics cite the possibility of neonatal water inhalation and maternal/neonatal infection.
To assess the evidence from randomised controlled trials about immersion in water during labour and waterbirth on maternal, fetal, neonatal and caregiver outcomes.
We searched the Cochrane Pregnancy and Childbirth Group’s Trials Register (October 2008).
Randomised controlled trials comparing any bath tub/pool with no immersion during labour and/or birth.
Data collection and analysis
We assessed trial eligibility and quality and extracted data independently. One review author entered data and another checked for accuracy.
This review includes 11 trials (3146 women); eight related to the first stage of labour, one to the first and second stages, one to early versus late immersion in the first stage of labour, and another to the
We identified no trials evaluating different baths/ pools, or the management of third stage of labour.
Results for the first stage of labour showed there was a significant reduction in the epidural/spinal/paracervical analgesia/anaesthesia rate amongst women allocated to water immersion compared to controls (478/1254 versus 529/1245; odds ratio (OR) 0.82, 95% confidence interval (CI) 0.70 to 0.98, six trials).
There was no difference in assisted vaginal deliveries (OR 0.84, 95% CI 0.66 to 1.06, seven trials), caesarean sections (OR 1.23, 95% CI 0.86 to 1.75, eight trials), perineal trauma or maternal infection.
There were no differences for Apgar score less than seven at five minutes (OR 1.59, 95% CI 0.63 to 4.01, five trials), neonatal unit admissions (OR 1.06, 95% CI 0.70 to 1.62, three trials), or neonatal infection rates (OR 2.01, 95% CI 0.50 to 8.07, five trials).
A lack of data for some comparisons prevented robust conclusions. Further research is needed.
Elizabeth R Cluett, lecturer in midwifery1, Ruth M Pickering, senior lecturer in medical statistics2, Kathryn Getliffe, professor of nursing1, Nigel James St George Saunders, medical director3
To evaluate the impact of labouring in water during first stage of labour on rates of epidural analgesia and operative delivery in nulliparous women with dystocia.
Randomised controlled trial.
University teaching hospital in southern England.
99 nulliparous women with dystocia (cervical dilation rate < 1 cm/hour in active labour) at low risk of complications.
Immersion in water in birth pool or standard augmentation for dystocia (amniotomy and intravenous oxytocin).
Main outcome measures
Primary: epidural analgesia and operative delivery rates. Secondary: augmentation rates with amniotomy and oxytocin, length of labour, maternal and neonatal morbidity including infections, maternal pain score, and maternal satisfaction with care.
Women randomised to immersion in water had a lower rate of epidural analgesia than women allocated to augmentation (47% v 66%, relative risk 0.71 (95% confidence interval 0.49 to 1.01), number needed to treat for benefit (NNT) 5).
They showed no difference in rates of operative delivery (49% v 50%, 0.98 (0.65 to 1.47), NNT 98), but significantly fewer received augmentation (71% v 96%, 0.74 (0.59 to 0.88), NNT 4) or any form of obstetric intervention (amniotomy, oxytocin, epidural, or operative delivery) (80% v 98%, 0.81 (0.67 to 0.92), NNT 5).
More neonates of women in the water group were admitted to the neonatal unit (6 v 0, P = 0.013), but there was no difference in Apgar score, infection rates, or umbilical cord pH.
Conclusions Labouring in water under midwifery care may be an option for slow progress in labour, reducing the need for obstetric intervention, and offering an alternative pain management strategy.
Slower than expected progress in the first stage of labour (dystocia) occurs in 20% of nulliparous women in labour and accounts for 20% of caesarean sections and 40% of instrumental deliveries, and results in longer hospitalisation.1 For women at low risk of complications, it marks the transition from midwifery to obstetric management.
Since proponents of active management first claimed the benefits of shorter labour and lower rates of caesarean section,2 3 debate has continued over conservative versus aggressive management and the medicalisation of birth.
Management strategies for dystocia vary from immediate augmentation4 5 to delayed intervention up to four hours after diagnosis.6-8 Comparison between strategies is difficult as specific features often differ; for example, one-to-one care is recognised to have beneficial effect on labour outcomes.9
Our current trial was based on two precepts. Firstly, that incomplete understanding of labour may lead to unnecessarily early intervention. Secondly, that anxiety and pain may trigger a stress response,10 leading to reduced uterine activity and dystocia.11
Labouring in water may ameliorate this stress response by aiding relaxation and pain relief. Few trials have evaluated labouring in water, perhaps because of the difficulty in randomising women who may have strong preferences.12
A Cochrane review concluded that, for women at low risk of complications, there was no clear evidence of advantage or disadvantage in using a pool in labour but further research was needed.13 Two national surveys concluded that labour and birth in water had no effect on perinatal mortality.14 15
In preparation for the trial reported here, we conducted a feasibility study comparing labour in water with augmentation and conservative management for women with dystocia,16 but conservative management was considered unacceptable by women and clinicians. Our current trial therefore compares labour in water with augmentation in nulliparous women with dystocia.
Participants and methods
Our randomised controlled trial compared immersion in water during the first stage of labour after diagnosis of dystocia with augmentation, the standard management for dystocia. We conducted the trial between January 1999 and December 2000 in a large university teaching hospital in southern England with about 4500 births a year.
Nulliparous women with a diagnosis of dystocia (cervical dilation of < 1 cm/hour)—who at that time would routinely have been advised to have their labour augmented by amniotomy or oxytocin infusion, or both—were eligible for the trial if they were able to give informed consent, had received information about the trial during their pregnancy (a leaflet describing the trial was distributed to all nulliparous women antenatally), were in spontaneous, active labour, and were at low risk of complications (full term, singleton pregnancies, fetus in cephalic presentation, and no medical, obstetric, or psychiatric problems).
After participating women were randomised, each management option consisted of a package of care provided by midwives, including one-to-one care. Labour progress was assessed by vaginal examinations every four hours and documented on a standard partogram. All women could request any form of analgesia available at any time.
Augmentation—Women in the augmentation group received the standard management for dystocia. Amniotomy was performed if the membranes were intact, and a midwife managed the labour for the next two hours unless otherwise clinically indicated.
If the membranes were already ruptured or progress was not satisfactory during the two hours after amniotomy, intravenous oxytocin was given, starting at 4 mU/min and doubled every 30 minutes, up to a maximum of 64 mU/min, until regular contractions (3-4 every 10 minutes) occurred. Continuous fetal monitoring was carried out.
Labour in water—Women allocated to labour in water used a permanent, acrylic, oval waterbirth pool measuring 154 cm by 184 cm by 77 cm and filled with still tap water without additives so that immersion was to above the breasts when sitting. Water temperature was maintained at 36.0-37.0°C.
The maximum stay in the pool before reassessment by vaginal examination was four hours. If labour progress was satisfactory (cervicaldilation 1cm/hour),subsequent care could continue in the pool if the woman wished, otherwise augmentation was advised.
We based our estimate of the potential effect size on an audit of 50 nulliparous women with dystocia in May-July 1997, who would have met the trial inclusion criteria.
We concluded that 220 women would be required to detect an absolute reduction of 25% in the rate of epidural analgesia (from 60% to 35%) and an absolute reduction of 20% in the operative delivery rate (from 40% to 20%) with 90% power in 5% two sided tests.
The local incidence of dystocia in nulliparous women meeting our eligibility criteria was about five a week (260 a year).
In our pilot study we obtained a consent rate of 71%,16 but we anticipated a lower rate when all midwives undertook recruitment, and therefore planned a recruitment period of two years.
Randomisation and recruitment
We used a computer generated randomisation schedule in balanced blocks of 20. Concealment was ensured by an independent person putting allocation details in sequentially numbered, opaque, sealed envelopes.
Ten consecutively numbered envelopes were stored in the labour ward at any one time and audited daily to ensure they were intact.
After dystocia was diagnosed, a midwife who had received training in patient recruitment checked that the woman in question had received the information leaflet about the trial, assessed her eligibility for the study, and, if suitable, sought her informed consent.
When a woman agreed to participate the midwife opened the next trial envelope to allocate the woman to a treatment arm and to give her a unique trial number. Participation in the trial was recorded in the woman’s routine maternity records.
Primary outcome measures were epidural analgesia and operative delivery (ventouse, forceps, or caesarean section).
Secondary measures included augmentation rates (receiving amniotomy or oxytocin, or both) and maternal or neonatal morbidity (any infection, admission to the neonatal unit, or condition that required medical care up to the 10th postpartum day).
Obstetric data were recorded in the maternity records by practitioners and abstracted after discharge from maternity care.
It was not possible to conceal allocation from clinical practitioners or at the time of data abstraction as care provided was clearly documented. However, as data were objective in nature and recorded contemporaneously observer bias was minimised.
We conducted a postpartum structured interview in the maternity unit to assess retrospectively the women’s experience of pain at 30 minutes after the intervention started and change in pain over the same time period (measured with visual analogue scales of 0 to 100 mm for pain experience and -50 mm to +50 mm for change in pain).
We did not assess pain concurrently because of the disruption to the women and midwives. We also assessed women’s satisfaction overall and in relation to privacy and freedom of movement (asked as separate questions) using four point Likert scales.
We chose to use a structured interview format to reduce potential bias because it was not possible to keep the interviewer blinded to women’s treatments as their comments made the allocation apparent.
We analysed results on an intention to treat basis. We compared rates of epidural analgesia and operative delivery between groups using Pearson’s ￼2 tests and presented results as relative risks with 95% confidence intervals. When numbers were small we calculated exact P values and confidence intervals in StatXact-5.
We produced numbers needed to treat to produce benefit in one woman and calculated confidence intervals as the inverse of the confidence interval about the absolute risk difference.
Confidence intervals around the numbers needed to treat for non-significant differences include the numbers needed to treat to produce harm,17 showing that results are not inconsistent with the intervention producing worse outcome.
We used Mann-Whitney tests to compare length of labour and women’s pain and satisfaction scores, and presented confidence intervals for differences in means.
A confidential summary of the safety data was prepared after 50 women had been randomised, and assessed by an obstetric consultant independent of the trial, who recommended that recruitment continue.
Of 3825 nulliparous women who delivered in the unit during the two years of recruitment, 741 were defined as being at low risk of complications at the time of the diagnosis of dystocia (see figure). Consent was sought from 176 eligible women, of whom 99 (56%) agreed to participate, and were randomised.
The two groups of women showed no important differences in baseline characteristics (table 1). There was good adherence to the trial protocol, with 48 of the 49 women allocated to labour in water using the pool, and 48 of the 50 women allocated to standard care receiving augmentation.
The woman who declined to enter the water requested an amniotomy. Two women in the augmentation group progressed before augmentation could be started.
Twenty three women (47%) allocated to labour in water received epidural analgesia after randomisation compared with 33 (66%) in the augmentation group (relative risk 0.71 (95% confidence interval 0.49 to 1.01), number needed to treat 5) (table 2).
The numbers of operative deliveries (caesarean sections and ventouse and forceps deliveries) were similar in both arms of the trial, with 24 (49%) women allocated to labour in water receiving an operative delivery compared with 25 (50%) women allocated to augmentation (relative risk 0.98 (0.65 to 1.47), number needed to treat 98).
Twenty five of the 27 women in the water labour arm who had made slow progress at the assessment four hours after recruitment received augmentation.
A further three women progressed slowly subsequently and also received augmentation. Seven women who progressed satisfactorily received an amniotomy for other indications.
The number of women who received augmentation (amniotomy or oxytocin) in the water labour arm was significantly lower than that in the standard care arm (35 (71%) v 48 (96%), relative risk 0.74 (0.59 to 0.88), number needed to treat 4) (table 2).
The mean duration of the first stage of labour was similar in the two groups, 10.47 hours in the water labour group and 10.26 hours in the augmentation group (table 3).
Women allocated to labour in water reported significantly lower mean pain scores at 30 minutes after start of the allocated management (49 mm v 64 mm) and a reduction in mean pain (-26 mm) compared with an increase for women receiving augmentation (12 mm).
Women allocated to labour in water were more likely to report satisfaction with freedom of movement (91% v 63%) and with experience of privacy (96% v 81%), but there was no difference between groups in overall satisfaction (table 3).
Maternal and neonatal wellbeing
Maternal and neonatal infection rates were similar in the two groups (table 4), as was neonatal condition at birth indicated by Apgar score and umbilical cord pH. Six neonates born to women in the water labour group were admitted to the neonatal unit compared with none in the augmentation group (P = 0.013).
The reasons for admission were: cardiac defects (1), hypothermia (2), fever (1), suspected infection on day 2 (1), and poor feeding on day 3 (1). There was a mean delay of 6 hours (range 2-10 hours) between women leaving the pool and birth.
With the exception of the infant with cardiac defects, all these neonates, who had required an operative delivery, were reunited with their mothers within 48 hours and experienced no subsequent problems.
This is the first trial to evaluate the impact of labouring in water for nulliparous women with dystocia. Compared with women given standard augmentation, the women labouring in water had no difference in operative delivery rates and tended to receive less epidural analgesia.
Before this trial it had been suggested that as all the women would have dystocia, augmentation would be inevitable, along with longer labour, and/or assistance in the second stage of labour.
However, almost 30% of women in the water arm did not receive augmentation and 20% received no obstetric intervention, without evidence of longer labour, both of these rates being significantly different from the augmentation arm. In addition, women retrospectively reported less pain and increased satisfaction.
Our findings suggest that delaying augmentation in association with a supportive environment (water immersion) is acceptable to women with dystocia and may reduce the need for epidural analgesia without increasing labour length or operative deliveries.
This is important, as it has been suggested that women prefer earlier intervention.7
Also a management approach that reduces rates of augmentation and associated obstetric intervention may contribute positively to maternal physiological and psychological health: oxytocin infusion is known to increase the risk of uterine hyperstimulation and fetal hypoxia, and obstetric interventions are associated with lower maternal satisfaction.18
A reduced need for epidural analgesia and augmentation may enable staff and other resources to be used differently—for example, allowing more women to receive one-to-one care in labour.
Maternal and neonatal wellbeing
The trial was not large enough to detect differences in maternal and fetal morbidity. However, indicators of wellbeing were similar in the two groups, with the exception of increased admission to the neonatal unit after labour in water.
Possible reasons for this include the water immersion itself, the delay in intervention of up to four hours (even though this did not affect overall labour length), extra caution by practitioners when women were known to have laboured in water, or chance factors with no direct relation to the trial.
No other studies of labour in water have reported such an association: instead, they either did not provide data on admissions to neonatal units19 20 or reported only one admission21 or similar admission rates in both trial arms.22
Eckert et al reported an increased incidence of initial resuscitation measures with water immersion,22 but we found no difference in Apgar scores and blood gas analysis at birth.
Indeed, three of the admissions to the neonatal unit were between nine and 48 hours after delivery, while the three admissions immediately after birth were associated with temperature regulation.
Comparative studies of labour in water found no increase in admissions to neonatal units or other markers of neonatal distress.23-25 It is clearly important to ensure ongoing audit of neonatal outcomes for women who labour in water.
Limitations of study
Only 99 of the intended 220 women were recruited for a variety of reasons. In common with other trials18 epidural analgesia was the main reason why nulliparous women with dystocia were ineligible for our study (28%).
Local rates of epidural analgesia and their likely impact on recruitment should feature as part of the planning of any future trials involving labour management.
In our busy maternity unit recruitment was not a priority, and some eligible women were not invited to participate in our study. The main reason eligible women chose not to enter the trial was a preference for one or other form of care (40%).
This is a recognised problem, and consideration is needed on how this may affect the generalisability of our findings and ways to overcome recruitment problems.
Recruitment became more difficult towards the end of the trial because of the adoption of a more conservative approach to managing dystocia in the unit and the introduction of the modified World Health Organization partogram,6 which incorporates a delay between the identification of slow progress and augmentation.
During this delay midwives could facilitate ongoing conservative management; as a consequence, they were less willing to recruit women to the trial, knowing that half of the women would immediately receive augmentation.
Thus, the trial was not continued past the planned two years. The low recruitment rate contributed to the outcomes achieved, such as the lack of statistical significance in relation to the difference in rates of epidural analgesia.
For women in normal labour, immersion in water is associated with less need for analgesia and increased satisfaction
Augmentation of labour, in particular oxytocin administration, is associated with hyperstimulation and decreased maternal satisfaction
For nulliparous women with dystocia (cervical dilation < 1 cm/hour), immersion in water for up to four hours seemed to reduce need for augmentation of labour, reduce pain, and increase satisfaction, without increasing overall length of labour or operative delivery rate
Water immersion may be an alternative option to early augmentation of labour
We thank the women who participated in the trial; the midwives and obstetric and support staff of the unit where the trial was conducted; research advisory group members Maggie Elliot and Debbie Gould; and Rona McCandlish for her support in preparing this paper.
Contributors: ERC was principal investigator and research midwife and was responsible for trial design and coordination, and data collection and analysis, supported by RMP and KG as research supervisors. NJS contributed to the initial idea and enabled the trial in the clinical setting.
All authors helped to write the paper. ERC acts as guarantor for the paper.
Funding: Southampton University Hospitals NHS Trust.
Competing interest: None declared.
Ethical approval: Approval was given by the local research ethics committee.
10. Brownridge P. The nature and consequence of childbirth pain. Eur J Obstet Gynecol Reprod Biol 1995;32(suppl): S9-15.
16. Cluett ER, Pickering RM, Brooking JI. An investigation into the feasibility of comparing three management options (augmentation, conservative and water) for nulliparae with dystocia in the first stage of labour. Midwifery 2001;17: 35-43.
17. Altman DG. Confidence intervals for the number needed to treat. BMJ 1998;317: 1309-12. 18. Green JM, Coupland VA, Kitzinger JV. Great expectations. A prospective study of women’s expectations and experiences of childbirth. 2nd ed. Cheshire: Books for Midwives, 1998. 19. Schorn MN, McAllister JL, Blanco JD. Water immersion and the effect on labor. J Nurse Midwifery 1993;38: 336-42.
25. Ohlsson G, Buchhave P, Leandersson U, Nordstrom L, Rydhstrom H, Sjolin I. Warm tub bathing during labor; maternal and neonatal effects. Acta Obstet Gynecol Scand 2001;80: 311- 4.
Barbara Harper 2000
Waterbirth is simple.
Within the simplicity of water labor and birth lies a complexity of questions, choices, opinions, research data, women’s experience and practitioner observations.
Over the past five years, as more hospitals within the United States examined waterbirth and created programs to support the use of water for labor and birth, newspaper reporters latched onto the sensationalism of this simple option and published stories of successful waterbirths in local publications.
Reporters do their best to simplify waterbirth and at the same time answer the most common questions. Each story shows a happy, beaming mother, a quiet, peaceful baby and a proud father, who usually successfully sets up a portable birth pool.
The surprise headlines like “Watery Birth” or “Baby’s Birth Goes Swimmingly” or “Junior Makes a Splashy Entrance” are countered with the simple stories of couples who have made this decision for themselves and are proud of it.
The first and foremost question in everyone’s mind and the lead in all these newspaper accounts is simple: How does the baby breathe during a waterbirth?
Several factors prevent a baby from inhaling water at the time of birth. These inhibitory factors are normally present in all newborns. The baby in utero is oxygenated through the umbilical cord via the placenta, but practices for future air breathing by moving his/her intercostal muscles and diaphragm in a regular and rhythmic pattern from about ten weeks gestation on.
The lung fluids that are present are produced in the lungs and are similar chemically to gastric fluids. These fluids come up into the mouth and are normally swallowed by the fetus. There is very little inspiration of amniotic fluid in utero.
Twenty-four to forty-eight hours before the onset of spontaneous labor, the fetus experiences a notable increase in the prostaglandin E2 levels from the placenta which causes a slowing down or stopping of the fetal breathing movements (FBM).1 With the work of the musculature of the diaphragm and intercostal muscles suspended, there is more blood flow to vital organs, including the brain.
You can see the decrease in FBM on a biophysical profile, as you normally see the fetus moving these muscles about 40 percent of the time. When the baby is born and the prostaglandin level is still high, the baby’s muscles for breathing simply don’t work, thus engaging the first inhibitory response.
A second inhibitory response is the fact that babies are born experiencing acute hypoxia or lack of oxygen. It is a built-in response to the birth process. Hypoxia causes apnea and swallowing, not breathing or gasping.
If the fetus were experiencing severe and prolonged lack of oxygen, it may then gasp as soon as it was born, possibly inhaling water into the lungs.2 If the baby were in trouble during the labor, there would be wide variabilities noted in the fetal heart rate, usually resulting in prolonged bradycardia, which would cause the practitioner to ask the mother to leave the bath prior to the baby’s birth.
The temperature differential is another factor thought by many to inhibit the newborn from initiating the breathing response while in water. The temperature of the water is so close to maternal temperature that it prevents any detection of change within the newborn.
This is an area for reconsideration after increasing reports of births taking place in the oceans, both now and in eras past. Ocean temperatures are certainly not as high as maternal body temperature, yet babies that are born in these environments are reported to be just fine. The lower water temperatures do not stimulate the baby to breathe while immersed.
One more factor that most people do not consider but which is vital to the whole waterbirth and aspiration issue is the fact that water is a hypotonic solution and lung fluids present in the fetus are hypertonic. Even if water were to travel in past the larynx, it could not pass into the lungs based on the fact that hypertonic solutions are denser and prevent hypotonic solutions from merging or coming into their presence.
The last important inhibitory factor—the dive reflex—is associated with the larynx. The larynx is covered all over with chemoreceptors, or taste buds. In fact, the larynx has five times as many taste buds as the whole surface of the tongue.
When a solution hits the back of the throat and crosses the larynx, the taste buds interpret what substance it is and the glottis automatically closes; the solution is then swallowed, not inhaled.3
God built this autonomic reflex into all newborns to help them breastfeed, and it is present until about the age of six to eight months when it mysteriously disappears. The newborn is very intelligent and can detect what substance is in its throat.
It can differentiate between amniotic fluid, water, cow’s milk or human milk. The human infant will swallow and breathe differently when feeding on cow’s milk or breastmilk due to the dive reflex.
All these factors combine to prevent a newborn who is born into water from taking a breath until he is lifted up into the air.
Baby’s First Breath
What initiates the breath in the newborn? As soon as the newborn senses a change in the environment from the water into the air, a complex chain of chemical, hormonal and physical responses initiate the baby’s first breath.
Water born babies are slower to initiate this response because their whole body is exposed to the air at the same time, not just the caput or head as in a dry birth. Many midwives report that water babies stay a little bit bluer longer, but their tone and alertness are just fine. It has even been suggested that water born babies be given the first APGAR scoring at one minute thirty seconds, not at one minute, because of this adjustment.
Several things happen all at once in the baby. The shunts in the heart are closed; fetal circulation turns to newborn circulation; the lungs experience oxygen for the first time; and the umbilical cord is stretched causing the umbilical arteries to close down.
Nursing and medical schools taught their students for years that the first breath was dependent on the pressure of the passage through the birth canal, and then a reflexive opening of the compressed chest creating a vacuum.
That action has no bearing on newborn breathing whatsoever. There is no vacuum created. The newborn born into water is protected by all the inhibitory mechanisms mentioned above and is suspended and waiting to be lifted out of the water and into mother’s waiting arms.
All the fluids present in the lung alveoli are automatically pushed out into the vascular system from the pressure of pulmonary circulation, thus increasing blood volume for the newborn by one-fifth (or 20 percent).
The lymphatic system absorbs the rest of the fluids through the interstitial spaces in the lung tissue. The increase of blood volume is vital for the baby’s health. It takes about six hours for all the lung fluids to disappear.4
Outcomes and Concerns
When we look back at the analysis of the statistics of babies born in water it proves that these inhibitory factors are more than theories. A study conducted in England between 1994 and 1996 and published in 1999 reports on the outcomes of 4,032 births in water. Perinatal mortality was 1.2 per 1,000, but no deaths were attributed to birth in the water. Two babies were admitted to special care for possible water aspiration.5
It is estimated that there have been well over 150,000 waterbirths worldwide between 1985 and 1999. There are no valid reports of infant deaths due to water aspiration or inhalation. In the early days of waterbirth a baby was reported to have died from being born in the water.
This particular newborn death was caused not by aspiration, but by asphyxiation because the baby was left under the water for more than fifteen minutes after the full body was born. At some point the placenta detached from the wall of the uterus and stopped the flow of oxygen to the baby.
When the baby was taken out of the water, it did not begin breathing and could not be revived. On autopsy the baby was reported to have no water in the lungs and its death was attributed to asphyxia.6
This is the reason we bring babies up out of the water within the first few moments after birth. Some people have commented on the long time that some babies remain in the water in the film “Water Babies: The Aquanatal Experience in Ostend.” Videotape is deceiving, but so are our senses. When timed, the film sequence is only forty-seven seconds, but when viewers are asked to judge how long the sequence of immersion for the baby really is, reports range anywhere from one minute to five minutes.
Bringing a baby out of the water too quickly can be just as traumatic, but it can also lead to either torn or broken cords. This has been reported by a number of midwives and doctors.7 If the practitioner does not look for a torn cord the possibility of the baby needing a transfusion increases.
Torn or broken cords can be avoided by bringing baby out of the water slowly and gently. Mothers who want to pick up their own babies need to be reminded not to do it too quickly either.
The inability to accurately assess blood loss in the water is a reason given by some midwives for either not “allowing” the birth to take place in the water or asking mother to get out right away after the baby is born. But blood loss is easy to judge after a few births.
Garland and Jones report in a review of waterbirths at Maidstone Hospital in Kent, England, that midwives are much better at judging and reporting blood loss in the water after experiencing over 500 births.8 A useful way to identify the extent of postpartum hemorrhage is how dark the water is getting.
Can you still assess skin color of the mother’s thighs even though there is blood in the water? A few drops of blood in a birth pool diffuse and cause the water to change color. A waterproof flashlight comes in handy at this point.
Dropping a flashlight onto the bottom of the birth pool allows you to look for bleeding as well as meconium during the birth. It also helps you spot floating debris so it can be removed.
This brings us to the second most frequently asked question among hospital nurses and newspaper reporters: Won’t the mother get an infection?
Some hospitals still restrict a woman from laboring in the water if her membranes are ruptured. Based on the current and past literature, this is absurd. No evidence exists of increased infectious morbidity with or without ruptured membranes for women who labor and/or birth in water. 9 ,10
The oldest reference that researches the possibility of infection during a bath is mentioned in a 1960 American Journal of OB/GYN.
Dr. Siegel posed the question, “Does bath water enter the vagina?” In his experiment he placed sterile cotton tampons into thirty women and then asked them to bathe in iodinated water for a minimum of fifteen minutes.
In all cases when the tampons were removed, there was no iodine present.11 His conclusion states, “We can now stop restricting women from bathing in the later stages of pregnancy and labor.”
Laboring mothers have an advantage when the baby is descending and moving out—nothing is moving up and in. Things that we put into laboring vaginas may cause infections, such as probes, fingers, AmnihooksTM, scalp hooks and so on. Janet Rush, RN, and her Canadian group of investigators have conducted the only randomized controlled trial of the effects of water labor.
They reported that there were no differences noted in the low rates of maternal and newborn signs of infection in women with ruptured membranes.12
Infection control, especially in a hospital setting, requires diligence and the attention to strict protocols between and during births. Cleaning and maintaining all equipment used for a waterbirth will prevent the spread of infection.
In a random study conducted at the Oregon Health Science University Hospital in 1999, cultures were done from the portable jetted birth pool before, during and after birth, as well as from the fill hose and water tap source.
In all instances no bacteria was cultured from the birth pool but the water tap did culture Pseudomonas.13 In a British study of 541 water labors, no serious infections were reported during the three-year period of data gathering.
Again, Pseudomonas aeruginosa was the only persistent bacteria discovered in two babies who tested positive from ear swabs. No treatment was necessary.14
Some parents are concerned about mother-to-mother infections or contamination from viruses such as HIV or hepatitis. There is no reason to restrict an HIV-positive mother from laboring or giving birth in water.
All evidence indicates that the HIV virus is susceptible to the warm water and cannot live in that environment.15 Universal precautions still need to be adhered to and proper cleaning of all the equipment after the birth needs to be carried out.
Using disposable liners has become the norm for use with portable birth pools, but attention must also be paid to proper cleaning of drain pumps, hoses, filter nets, taps and any other items that are reused from one birth to the next. The issue of cleaning the jets of permanently installed baths has generated some concern and discussion over the past few years.
Many hospitals remodeled their labor units in the late eighties or early nineties, installing Jacuzzi-type whirlpool baths. These baths are great for women in labor, but often are not deep enough or are situated within very small bathroom spaces, boxed in and making birth in them difficult in all respects.
The protocol for cleaning jetted tubs is simply to completely clean the tub with a quaternary ammonium solution, refill with water and add some kind of brominating agent to circulate through the jet system for a minimum of ten minutes.16
A number of hospitals report that they use a half cup of powdered dish-washing crystals such as Cascade, and it works fine. Lynn Springer, RN, the perinatal coordinator for St. Elizabeth Hospital in Red Bluff, California, chose to install a beautiful corner Jacuzzi brand jetted bath on her unit in 1995.
They have routinely performed monthly cultures of the bath and the jets throughout the past five years of their waterbirth program without any significant bacterial growth. They follow the above-mentioned cleaning protocol and report over 1,000 water labors and 400 births in water.17
When to Enter the Bath
One issue that is repeated in the literature and voiced in the concern of mothers and their midwives is: When should the mother enter the bath?
Many hospitals use the five-centimeter rule, only allowing mothers to enter the bath when they are in active labor and dilated to more than five centimeters.
Some physiological data supports this rule, but each and every situation must be evaluated and then judged. Some mothers find a bath in early labor useful for its calming effect and to determine if labor has actually started.18
The water sometimes slows or stops labor if used too early. On the other hand, if contractions are strong and regular with either a small amount of dilation or none at all, a bath might be in order to help the mother relax enough to facilitate the dilation.
It has been suggested that the bath be used in a “trial of water” for at least one hour, allowing the mother to judge its effectiveness. Women report that often the contractions seem to space out or become less effective if they enter the bath too soon, thus requiring them to leave the bath.
Then again, midwives report that some women can go from one centimeter to complete dilation within the first hour or two of immersion.
Deep immersion seems to be a key factor. If the pool or bath is not deep enough, at least providing water up to breast level and completely covering the belly, then the benefits of the bath may be less noticeable.
The warm water will still provide comfort and the mother will benefit from being upright, in control and drug free, but full immersion promotes more physiological responses, the most notable being a redistribution of blood volume, which stimulates the release of oxytocin and vasopressin.19
Vasopressin can also work to increase the levels of oxytocin.20 The immediate pain reduction felt upon entering the bath is quite noticeable. It is what I refer to as “the ahh effect.”
The smile, the sound and the inner peace that mothers display are unmistakable. This response can happen at any point in the labor, but most notably when contractions are long and strong and close together.
Some midwives who assume there is little or no progress in dilation because the mother is not displaying any outward signs of discomfort are often surprised to find rapid dilation in the first hour of immersion. Having experienced a waterbirth myself, I can verify the incredible difference in perception of pain from the room to the water.
When I am with a woman in labor I generally assess her pain on a scale of one to ten before she enters the bath. Most report at least a six or greater. Then after no less than half an hour, I will make another assessment.
The second subjective answer of course varies from person to person, but the typical response is two to four. The mother is experiencing more than the sum of her physiological responses to warm water immersion. Most women feel inherently safe in the water.
The water creates a wonderful barrier to the outside world. It becomes the woman’s nest, her cave, her own “womb with a view.” If the pool is large enough to include her partner or husband, it then becomes an intimate place for the two of them to labor together and experience the love dance of birth.
If the midwife or physician wants to do a vaginal examination while the mother is in the water, it is much easier for the mother to refuse. Her mobility allows her to move quickly to the other side of the pool. Vaginal exams can be easily done in the water, but to maintain universal precautions, long shoulder-length gloves need to be worn.
The control that women gain by being able to move freely in the water often helps them assess their own progress either by feeling the baby’s movements more intensively or actually being able to examine themselves internally.
Women report that the water intensifies the connection with the baby at the same time that it reduces the pain. They can feel the baby move, descend and push through the birth canal.
The prospect of the midwife becoming an active observer increases as mothers have the ease of mobility in the water and assume more and more responsibility for the birth.
For many reasons, including reducing the risk of infection for the provider, many midwives suggest a hands-off birth for the mother. The water slows the crowning and offers its own perineal support.21 This “minimal-touch” approach also gives the mother a greater sense of controlling her own birth.
Perineal trauma is reported to be generally less severe, with more intact perineums for multips, but in some of the literature about the same frequency of tears for primips in or out of the water.22 23 One of the best benefits of waterbirth is the zero episiotomy rate that is reported throughout the literature.
Rosenthal mentions that episiotomies can be done, but no one else offers this suggestion.7
The combination of being upright, having the mother in a good physiological position to birth her baby, giving her the freedom of control and not telling her to push when her body is not indicating it, all contribute to better perineal outcomes.
The Midwife’s Influence
Midwives have a great deal of influence over the outcome of a birth, from the suggestions they make to a laboring mother to how they handle potential complications. An interesting phenomenon within the waterbirth movement deserves some discussion.
When a mother is laboring undisturbed—about which Odent has written and lectured—she will find her own place and time of birth, whether that place is the bathroom floor, under the piano, on the bed or in the bath.
If practitioners remain silent observers to the process, the baby is born wherever it happens. But when the mother has stated her intentions for a waterbirth and the necessary arrangements have been made to have water available, if then the midwife reminds her as second stage approaches or in the middle of second stage that the bath is ready and waiting if she wants to get back in— is the midwife influencing the mother?
In observing the statistics on waterbirth that Waterbirth International gathers from midwives and doctors, it is hard not to notice the variance from practice to practice.
Those midwives who report an 80 to 90 percent waterbirth rate are usually set up with either a birth center facility that uses easily accessible bathtubs, or every single one of their homebirth clients rent or use portable birth pools.
When the mother is in the midst of her subconscious birth responses and someone tells her that the bath is ready and waiting, she often will immediately dash for the pool and climb in, even in the pushing stage. On occasion she simply states that nothing in heaven and earth can move her beyond where she is.
A midwife’s or physician’s hesitancy for using water for birth can also be felt by the mother and she often acquiesces just to make her practitioner feel more comfortable, instead of following her own instincts and staying in the water. Many women in hospitals get out of the pool because they don’t want to get their midwives “in trouble” by insisting on giving birth in water.
And in the reverse, midwives often must insist that mother get out of the pool because protocols have not been set up for birth or the practitioner is just not comfortable with the process.
The decision to birth in the water should be left up to the mother, but based on sound advice and assessment of fetal well-being by the practitioner. The mother who presents prenatally and insists she is going to have a waterbirth no matter what is usually destined to birth anywhere but the birth pool.
I seriously counsel women who are taking on the system to evaluate their reasons for wanting to birth in water. If they are seeking only to avoid pain, that is a serious red flag and needs to be addressed on many different levels.
If they have experienced one birth already and know what to expect and are looking for a better birth experience, then they are usually open to using the water to be in greater control, and then seeing how they feel at the time of birth.
Flexibility is always required in birth, but especially for those women who add the element of water. In my own case, I wanted to birth in water the first time because I felt it was the best thing I could do for my baby. I hear many women say this, and I consider it a reasonable motivation.
But it is better to focus on the mother and what she needs; the benefit that women derive from being in the water and gaining control over their experience is passed on to the baby. For my second waterbirth, no one could keep me out of the water. I was completely focused on my experience and not the baby’s.
Fathers will often call our office and make all the arrangements for the birth pool rental. On occasion that is because the dad wants his baby to be born in water and no other place, not taking into account what the mother really wants. Usually it all works out just fine, but occasionally it can influence the outcome of the labor.
Protocols differ from place to place, but as more experience with waterbirth emerges, we find that some previous reasons for asking a woman to leave the bath prior to birth are no longer hard and fast.
The prescence of meconium used to mean that the mother would have to leave the pool to birth her baby on the bed to facilitate immediate suctioning. This requirement has relaxed a bit as it has been seen that meconium washes off the face of the baby and even comes out of the nares and mouth while the baby is still under the water. DeLee suctioning can still be accomplished as soon as the baby is up in mother’s arms.
Tight nuchal cords were a reason to ask mother to stand for the birth so that the practitioner could cut the cord and then deliver the baby. Now the universal practice is to not even feel for a cord in a waterbirth, unless there has been a very slow second stage and you are afraid of cord compression.
No attempt is made to clamp and cut the cord. The body is birthed and then the cord unwrapped. It is amazing to watch a baby somersault and begin to unwrap its own cord in the expanse of the birth pool.
Breech position was definitely a reason for a more controlled birth or even an automatic cesarean section. But there are practitioners throughout the world who recognize increased safety for the baby if it is born in water.
The most experienced doctor we know is Herman Ponette, an obstetrician who practices at H. Serruys Hospital in Ostend, Belgium. He has attended well over 2,000 waterbirths including breeches and twins.
He uses a frank breech position as an indication for a water birth.24 There are other reports of a few hospitals in the United States attending breech waterbirths, and approximately fifty reported breech births in water at home.25
Shoulder dystocia is considered an obstetric or midwifery emergency by most practitioners. Protocols require mothers who are anticipating large babies to leave the bath. Now there is a growing body of experience that suggests shoulder dystocia can be managed easier in the pool.
Canadian birth attendant Gloria Lemay has written a protocol for management of shoulder dystocia in the water. It appears that tight shoulders happen more often because of practitioners or moms trying to push before the baby fully rotates.
There is no harm in waiting for a few contractions to allow baby to rotate, especially since the baby is not going to be taking a breath. Position changes in the water are so much easier to effect and the mother doesn’t panic but remains calm.
A quick switch to hands and knees or even to standing up with one foot on the edge of the pool if shoulders are really tight can help maneuver baby out.
Prematurity has always been considered a reason for a controlled and monitored bed birth. Some doctors who have experienced the great results of waterbirth for babies born from thirty-six weeks gestation on are now questioning whether waterbirth might be good for some babies who are less than thirty-six weeks gestation.
With the advances for waterproof fetal monitoring there are fewer reasons to require a woman to leave the pool, especially if her baby is tolerating the labor well.
A few cases of waterbirth for thirty-three, thirty-four and thirty-five-week-old babies have been reported.
The Waterbirth Choice
Once a woman has experienced a waterbirth she will more than likely want to repeat the experience. To that end, Waterbirth International gets some pretty interesting referral requests from women all over the world.
If circumstances have changed and the mother is no longer living in a place where waterbirth facilities or practitioners are readily available, she will go to almost any length to recreate the opportunity to give birth in water.
A research project that Waterbirth International has been conducting for ten years is a survey of women who have given birth in water.
One question on the survey form asks: “Would you consider giving birth again in water?” With over 1,500 surveys collected, only one woman answered no to that question.
On her particular survey she emphatically stated no in bold print with two exclamation points and then drew an arrow down to the bottom of the page where in very small print she wrote, “This is number seven, I’m done!”
It is hard to think of another “method” of childbirth that receives such praise from women and practitioners alike. Dr. Lisa Stolper is an obstetrician practicing in the quaint New England town of Keene, New Hampshire.
She began offering waterbirth to her clients at Cheshire Medical Center in October 1998. One year later she reported an overall waterbirth rate of 37 percent for all vaginal births and 33 percent for all births, including cesarean sections.
Her hospital has purchased just one portable jetted birth pool, but they use it for the labor of almost 50 percent of their clients.
They are now considering installing permanent pools to make them available for more women. Her comment about her job as an obstetrician was, “Waterbirth just makes my job so much easier.”
One of the final questions that newspaper reporters pose and birthing couples ask is, why aren’t more hospitals in the United States offering waterbirth?
Hospitals in the United States have made incredible advances in the waterbirth movement in the past five years. Monadnock Community Hospital in Peterborough, New Hampshire, was the first hospital in the country to embrace waterbirth and install a permanent birth pool; the pool was imported from England.
They still offer this option to women and can now look back on almost ten years of great outcomes and lots of satisfied families. The rest of the country has taken some time, with certain areas of the country making greater strides than others.
In almost all cases where there are successful waterbirth programs, certified nurse-midwives have started them. Midwives are more open to exploring the issue with their clients and doing the research necessary to get protocols accepted in hospitals.
Some midwives have even purchased portable birth pool equipment with their own funds in hopes that it would pay for itself by generating more business. In most instances, that investment has paid off.
The whole U.S. movement is at least five years behind the European movement in acceptance in hospital environments, but homebirth midwives in the United States have been offering waterbirth longer than most of their European counterparts.26
The United Kingdom has had the benefit of government-sponsored research and data reporting as well as the Cumberledge Report.27 The House of Commons Health Committee recommended that all hospitals should provide women with the option of a birthing pool.
The underlying philosophy of the Changing Childbirth report recognized that women have the right to choose how and where they wish to give birth. In a 1994 statement, the UKCC stated, “ . . . waterbirth is preferred by some women as their chosen method for delivery of babies.
Waterbirth should therefore be viewed as an alternate method of care and management in labour and one which falls within the midwife’s sphere of practice.”28
The states that have made the most progress for hospital waterbirth are New York, Maine, New Hampshire, Illinois, Ohio, North Carolina and Massachusetts. Obviously, the East Coast is changing faster than the West Coast.
It is surprising to some people when they find out that the whole state of California only has a handful of hospitals that provide waterbirth services. More than two thirds of the birth centers in the United States offer waterbirth as an available option.
Mothers who call Waterbirth International wanting advice on how to get their particular hospital to allow them to have a waterbirth are advised that it takes three ingredients to make policy changes within a hospital setting:
1) a motivated mother;
2) an open and supportive practitioner;
3) a compassionate nurse manager or perinatal coordinator who is willing to take on the training of staff and the creation of new policy.
Waterbirth International will supply the necessary research studies, the sample protocols, the pool kits, the videos and the experience to help couples get policy changed, but without these first three components some hospitals will continue to deny the request. Time is the other factor. The more advance notice a hospital is given the better chances there are for change.
There are so many areas of waterbirth to explore. Waterbirth is more a philosophy of nonintervention than a method or way to give birth. Waterbirth combines psychology, physiology, technology, humanity and science.
Waterbirth is ancient and yet new at the same time.
Waterbirth embodies a spiritual aspect of birth that is hard to express. Cynthia, who gave birth in water, said it better: “The water made me so completely connected to my body and my baby.
The water held me and cradled me so that I could surrender more completely to this amazing and wonderful grace that was happening to me. This is the way that God intended childbirth to be.” 29
Immersion in water during labour was popularised as a formal method of analgesia by Odent in the 1970s (Beake 1999), and became widespread after the Winterton Report recommended that all maternity services provide women with the option to labour or deliver in water (House of Commons Health Committee, 1992).
As with all aspects of midwifery care, the use of water during labour and birth requires evaluation of associated benefits and risks, yet there are no large, collaborative, randomised controlled trials to date (Nikodem, 2000).
This paper clarifies the RCM’s position and recommendations to its members. It should be used in conjunction with local policies and guidelines.
Introduction It has been estimated that 50 per cent of maternity units now provide facilities for labour or birth in water, and that between 15% and 60% of the women attending those units choose to use these facilities.
The number of births occurring in water is much lower, however; between April 1994 and March 1996, a survey identified only 0.6% of births in England and Wales occurring in water, 9% of which were home births (Tookey and Gilbert, 1999).
These averages conceal wide variation, with some units passively or actively discouraging women from using water, while one birth centre reports up to 80% of women using water during labour, with up to 79% giving birth within the pool (Beech, 2000).
There is not enough evidence to evaluate the use of immersion in water during labour (Nikodem, 2000), but both potential benefits and adverse effects have been described in the literature. Beneficial effects include maternal relaxation, less painful contractions, shorter labours, less need for augmentation, less need for pharmacological analgesics, more intact perinea, and fewer episiotomies (Schorn et al, 1993; Garland and Jones, 2000).
Among the adverse effects discussed are unrealistic labour expectations, restricted mobility, infection, and the potential problem of the neonate inhaling water (Alderdice et al, 1995; McCandlish and Renfrew, 1993).
The systematic review produced by the Cochrane Library highlights that ‘although no significant adverse effects have been reported, the possibility of adverse outcome for the neonate should not be ignored’ (Nikodem, 2000).
There is clearly a need for more research, and midwives should give high priority to developing midwifery knowledge in this area. In the meantime, the available evidence does not justify discouraging women from choosing this increasingly popular option.
Women experiencing normal pregnancy, who choose to labour or deliver in water, should be given every opportunity and assistance to do so. RCM recommendations
1. All maternity units should develop policies and guidelines, underpinned by the available evidence, on the use of water in labour and birth. These should be developed in consultation with midwives, supervisors, and local user representatives.
2. Managers and supervisors should ensure that midwives acquire and sustain the competence, skills and confidence necessary to assist women who choose to labour or deliver in water (UKCC, 1992a; UKCC, 1992b; UKCC, 1998a).
3. Midwives should ensure they are competent to provide support to women who choose to use water, and should keep themselves updated on the research evidence in this area.
4. Midwives should audit and evaluate their practice, and the outcomes of labour and birth in water, in order to contribute to midwifery knowledge and the development of best practice.
5. All midwives should ensure their record keeping of labour and births in water is accurate and adheres to UKCC standards (UKCC, 1998b). Policies and guidelines for the use of water Every maternity unit should have, or should develop, policies and guidelines on the use of water in labour and birth.
These should be underpinned by the best available evidence, and should be developed in consultation with supervisors and user representatives. They should cover the following areas:
1. Professional expertise
The assistance of women to labour and deliver in water should be considered a core midwifery competence. However, some will have lacked experience in this area, and therefore appropriate education, training and supervision will be necessary. Continuing professional development in this area should be seen as a service requirement.
2. Information for choice
• All women should be offered information on the option of using water in labour and birth. There are no grounds for seeing this option as particularly suitable for, and acceptable to, certain groups of women on the basis of non-clinical criteria.
• All women who express an interest in the use of water should be given full verbal and written information, including where appropriate a copy of the unit’s policy. This should include any expectations of the woman (for example, on the supply of equipment), and what steps will be taken in the event of an emergency.
3. Criteria for use of water Criteria for use of water may include:
• Women’s informed choice
• Normal term pregnancy at 37+ weeks
• Singleton fetus with cephalic presentation
• No systemic sedation
• Spontaneous rupture of membranes < 24 hours Other non-clinical criteria – such as the availability of staff or equipment – may reasonably be deployed; however, as with all other areas of maternal choice, their obstruction of women’s informed decision-making should be actively kept to a minimum.
• Local policies should specify essential and desirable equipment for the use of water, and make clear who is responsible for supplying it. • All unit equipment should conform to British Safety Standards, and be checked by the Health and Safety Officer (RCM, 1998). 5. Health and safety
• Local infection control policies should cover the use of water in labour and birth, and midwives should ensure they implement universal precautions (RCM, 1998).
• Specialist health and safety advice should be sought to develop policies on pool cleaning.
• Health and safety advice on moving and handling should be adhered to at all times (RCM, 1999).
6. Additional professional issues
• Temperature: All midwives should understand the physiological basis of maternal and fetal hyperthermia, local guidelines should specify target temperatures for the water during delivery and birth (Steer and Deans, 1995; Garland and Jones, 2000). Maternal, core water and room temperatures should all be checked regularly.
• Analgesia: Local guidelines for the use of additional pain relief should be developed in consultation with an anaesthetist, and discussed with all women prior to labour. These should cover all forms of pain relief, including complementary therapies.
• Birth: Local guidelines should be developed to guide midwives on best practice during delivery. These should be underpinned by the best available evidence (Nikodem, 2000).
• Emergencies: Local guidelines should detail what steps are expected in an emergency situation. All midwives, and all women using water for labour or birth, should know and understand these steps.
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Acknowledgements This paper was developed with the assistance of Dianne Garland (Practice Development Midwife, Maidstone), YP Choo (Labour Ward Co-ordinator, Chelsea and Westminster Hospital) and Mary Coe (Community Midwife, Southampton). October 2000 Royal College of Midwives