The Use of Water for Labour and Birth



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Guidelines for the Use of Water

for Labour and Birth

|Subject: |Use of water for Labour and Birth |

|Number |026 |

|Ratified By: |Joint Forum |

|Date Ratified: | |

|Version: | |

|Executive Owner: |Consultant Midwife in Normal Birth |

|Name and Designation of Author: | |

|Date Issued: |April 2014 |

|Review Date: |October 2016 |

|Target Audience: |Midwives |

|Other Linked Policies/Documents: |Intrapartum care 088 |

|Key Words: |Waterbirth. |

This is a Controlled Document. Staff must refer to the Intranet version of this document to confirm the most up to date version of this clinical guide. Older versions are in circulation; they must be either returned to the contact person above or destroyed.

The Use of Water for Labour and Birth

Introduction

The healing and pain relieving properties of water have been hailed for centuries. Women find the water relaxing and a feeling of weightlessness may ease the pain of contractions. The National Service framework (2004) states that women should have access to a “birthing pool with staff competent in facilitating water births” (NSF 2004). This is also supported by NICE 2007. A Cochrane review of the use of water for labour reflects a reduction in use of epidural/spinal/paracervical blocks for pain relief, and reduction in women’s reported experiences of pain (Cluett et al. 2004). This review found no differences in regard to duration of first and second stages of labour, instrumental vaginal delivery, caesarean section, perineal trauma, Apgars less than seven at five minutes, admissions to neonatal units or neonatal infection rates.

Research by the National Perinatal Epidemiology Unit, commissioned by the Department of Health, studied the outcomes of 8.255 labours in birthing pools of which 4,494 births took place in water and concluded that water birth is safe and should be available to women (Alderdice 1995). Gilbert and Tookey (1999) also carried out a surveillance study of all consultant paediatricians and a postal survey of all NHS maternity units to compare perinatal morbidity and mortality for babies delivered in water with rates for babies delivered not in water. 4,032 deliveries in England and Wales occurred in water, the perinatal mortality and risk of admission to special care is similar for babies delivered in water and for low risk deliveries that do not take place in water. Water aspiration was reported in two babies and snapped umbilical cord in five, although there is no data available about the incidence of the latter for non-water births. There have, subsequently, been further reports from midwives of the potentially dangerous occurrence of snapped umbilical cords and the steps taken to detect and deal with this situation (Crow and Preston 2002). In a study by Burns’ involving consecutive sample of 2357 low-risk women who used a birthing pool between 1990-1998 compared with a group of women, matched for key factors, who gave birth between 1991-1998 in the same centre (2001). From two one-year sub-samples, women who used the pool were significantly more likely to give birth normally. Use of water during labour was associated with less epidural usage and more intact perinea.

Eriksson et al.'s study of early versus late bathing (before and after 5cm cervical dilatation) found early bathing was associated with an increase in the average length of first stage and an increased need for oxytocin and epidural anaesthesia (1997), although this study may have included women in both the latent and active phases of labour. There appears little to recommend the use of arbitrary points during labour to dictate when birth pools should or should not be used and no evidence to suggest that the use of water should be limited to a specific duration.

Information on the experiences of nine women who had used water immersion during labour was obtained in a qualitative study (Hall and Holloway 1998). Women felt that the use of water had supported their feeling of control and involvement in decision-making. A survey of 189 women who experienced water birth reported feelings of relaxation, relief, warmth and relief of pain on entering the pool (Richmond 2003). Amongst women who had a previous birth, water birth differed, as they felt more in control, more relaxed and found labour less painful.

In a review of the evidence NICE 2007 concluded that, labouring in water reduces pain and the use of regional analgesia. NICE also found that there was evidence of no significant differences regarding adverse outcomes when comparing labours with and without the use of water and that there is insufficient evidence on timing of use of water in labour. Although the evidence base is not discussed NICE recommends for women labouring in water, the temperature of the woman and the water should be monitored hourly to ensure that the woman is comfortable and not becoming pyrexial. The temperature of the water should not be above 37.5 °C.

Criteria for Using Pool

All Women who meet the Green Criteria for midwifery led care in the intrapartum period. All women who are in the Amber Criteria who have had an additional consultation and further information from the Consultant Midwife for Normal Birth and / or a Consultant Obstetrician and all other appropriate specialists. These women must have a management plan which demonstrates this input in their antenatal notes. There must also be documented evidence that all risks have been discussed in partnership with the woman and been understood. ( Appendix 3)

Practice Implications:

• Information should be available for all women requesting a water birth.

• Women should be informed that the use of water in labour is associated with a decreased need for epidural analgesia.

• Women should be informed that there is insufficient high-quality evidence to either support or discourage giving birth in water.

Care of the Woman labouring and delivering in the Pool

• A midwife must be in constant attendance while a woman is in the pool. 2 midwives should be present at delivery

• The pool should be filled to the level of the woman’s breasts when she is sitting in the pool.

• Timing entering the pool is the individual choice of the woman, she must be free to enter and leave as she wishes.

• The water temperature should be comfortable for the mother and at a level to avoid hyper/hypothermia and should be checked hourly.

• The temperature of the woman and the water should be monitored hourly to ensure that the woman is comfortable and not becoming pyrexial. The temperature of the water should not be above 37.5 °C.

• Recommended temperature range: The temperature during the first stage of labour should be maintained at 35-37 degrees centigrade and raised to 37-37.5 degrees centigrade for the second stage of labour to prevent hypo/hyperthermia and a shift in the fetal maternal gradient (Garland 1995, Johnson 1996)

• The foetal heart rate should be auscultated and recorded as per fetal heart monitoring guidelines

• The usual labour observations are carried out and recorded as appropriate.

• If a vaginal examination is necessary the woman should leave the pool for this to enable an accurate assessment of the progress of labour, except to check for full dilation.

• Entonox may be used if required.

• Faecal contamination should be removed, as E.Coli is a potential source of infection. Heavy contamination is a reason to ask the mother to leave the pool temporarily.

• The mother should be encouraged to drink plenty of water while in the pool.

• Monitoring the colour of the liquor is important therefore keeping the water as clear as possible with a sieve will enable the midwife to observe the water colour, i.e. blood or liquor. If the water becomes excessively soiled it can be emptied and refilled.

• The woman should be asked to shower pre use of the pool and to also ensure that any body lotions or oils are not on the skin as they will have an impact on the water quality for the second stage of labour.

• If the woman decides to deliver in the pool it is primarily a “hands off” procedure. Immersion in water changes the elasticity of the skin and the counter pressure of the water may enable the woman to push more steadily thus encouraging controlled delivery of the head with the minimal involvement of the midwife. Pushing should be non-directed as hurried pushing leads to maternal exhaustion and an imbalance between CO2 and O2 on the maternal/fetal circulation.

• There is no need to check for the cord at delivery as the basic principle states that if the cord has caused no fetal compromise during labour, which you would be aware from auscultation of the fetal heart rate then it is unlikely to cause problems at delivery. Cutting and clamping the cord, before the birth of the body, is not an option with birth in water as this would trigger respiration. Feeling for the cord underwater may stimulate fetal respiration.

• The baby should be born totally submerged as exposure to air will initiate respiration. When the baby is born he/she should be bought to the surface immediately to initiate breathing.

• Midwives should be alert to the possibility of snapping of the umbilical cord when water is used for birth.

• Faecal contamination is a source E. Coli infection therefore removal of faeces with a sieve is recommended.

• In an emergency situation the woman is asked to leave the pool and call for assistance. It is important to have discussed this with the woman in the antenatal period or prior to entering the pool so that she recognises the situation and can prevent delay in an emergency. Emergency equipment should be available in close proximity.

CRITERIA FOR MOTHER TO LEAVE THE BIRTHING POOL

• Maternal choice

• Meconium liquor.

• Maternal pyrexia ≥38

• Any deviations of fetal heart rate that is non-reassuring (NICE 2007)

• Temporarily for severe faecal contamination until pool cleaned and refilled.

• If contractions reduce or become ineffective. The woman may be able to re-enter the pool when or if contractions improve.

• If assistance is needed with the birth of head or shoulders.

6. Equipment needed

• Water thermometer

• Sonicaid, waterproof and battery operated

• Step for getting in and out of the pool

• Towels for woman and baby

• Disposable sieve

• Ensure all equipment is cleaned.

Summary of observations of the woman and baby in first stage of labour

|Observation |Frequency |

|Temperature |hourly |

|Blood pressure (BP) |4 hourly |

|Maternal pulse |1 Hourly |

|Fetal heart rate (FHR) |Hand Held aqua Doppler machine for one full minute immediately after a |

| |contraction every 15 minutes (NICE 2007) |

|Colour of amniotic fluid |half hourly and at each VE |

|Uterine contractions | |

|Duration strength & frequency |Every 30 minutes |

|Abdominal examination |4 hourly |

|Vaginal examination |4 hourly |

|Urine (test all specimens for ketones) |encourage woman to a pass urine regularly and at least every 4 hours |

• Summary of Observations in the second stage of labour

|Observation |Frequency |

|Temperature |Half hourly |

|Blood pressure (BP) and Pulse |1 hourly |

|Fetal heart rate (FHR) |Aqua handheld Doppler for one full minute immediately after a |

| |contraction every 5 minutes (NICE 2007) |

|Uterine contractions | |

|duration |Every 30 minutes |

|frequency | |

| Abdominal examination |Prior to vaginal examination |

|Vaginal examination |Offer hourly in active second stage |

|Urine (test all specimens for ketones) |As necessary (encourage woman to a pass urine every 2 hours) |

Care of the neonate:

Neonatal resuscitation equipment must be available in the delivery room.

• Once the baby is delivered it must be brought to the surface immediately and its mouth and nose kept above water level.

• The baby should be born totally submerged, as exposure to air will initiate respiration. When the baby is born he/she should be brought to the surface immediately to initiate breathing (Johnson 1996).

• Waterbirth babies do not always cry instantly

• Feel the baby’s heart rate and observe the baby’s colour assess Apgar score at 1 minute and five minutes.

• Ensure the cord is left attached and is still pulsating. Check the cord by feeling it is intact, as a snapped cord can be a life threatening emergency if left unnoticed (Crow & Preston, 2002).

• Several cases where the problem has gone unnoticed have had serious neonatal consequences (Crow & Preston, 2002)

Third Stage Management

• There is no consensus about whether or not the woman should leave the pool for delivery of the third stage.

• If the third stage is being actively managed then the midwife should assist the mother out of the pool onto the bed.

• Physiological third stage is an option for women in the pool as with all low risk women.

• It is not feasible to expect to accurately record the blood loss in the water. Clots are collected using a sieve and the estimated blood loss recorded as 500mls.

Health & Safety Issues

• The general principles of ‘universal precautions’ apply when birth takes place in water just as it does on dry land. Gauntlet gloves are available and theatre greens may be more appropriate for the midwives comfort.

• Backache and injury can be reduced by a minimal handling policy and midwives should avoid leaning over the pool for any length of time. The health and well being of midwives is very important. Water spillage can occur as the woman steps out of the pool. All water should be cleaned as quickly as possible.

• Contamination of any kind may have an effect on the baby. Visible solids should be removed with a sieve. If the midwife feels there is heavy contamination the woman should be advised to leave the pool.

• Hoses, mirrors (exception Howes mirror), sieves should be for single use only.

• ‘Howes’ mirror can be washed using a disposable cloth with ChlorClean solution ( Ratio of one tablet to one litre of cold tap water)

• Decontamination procedures for cleaning and disinfecting the pools are documented in Appendix 1 (for plumbed in birthing pools) and Appendix 2 (for portable birthing pools).

Appendix 1

Decontamination Procedure for Plumbed in Birthing Pools

Routine Cleaning

1. Routine cleaning should be carried out twice weekly regardless of use.

2. Wash hands prior to any decontamination procedure.

3. Wear protective gloves and an apron (PPE).

4. Run the taps for 5 minutes, ensuring that the hot water tap attains temperature.

5. Clean the pool with a neutral detergent solution (soapy water) rinse with tap water and dry with paper towels.

6. Remove PPE into clinical waste and wash hands.

Cleaning Prior To Use

1. Must be carried out prior to every use.

2. Wash hands prior to any decontamination procedure.

3. Always wear protective gloves and an apron (PPE).

4. Clean the pool with detergent solution ( soapy water) and rinse with tap water.

5. Remove PPE into clinical waste and wash hands.

Cleaning and Disinfection after Use

1. Wash hands prior to any decontamination procedure.

2. Always wear protective gloves and an apron (PPE). Use facial protection if necessary. Ensure good ventilation.

3. Check expiry date on product. (see base of ChlorClean container)

4. Make up a ChlorClean solution in the diluter provided by adding 5 tablets to 5 litres of water from the cold tap. (This dilution makes a 1,000 ppm available chlorine solution).

5. Remove gross soiling from the water using single use sieve and discard into a clinical waste sack.

6. Drain the pool and remove any remaining organic soiling with paper towels, use single use tweezers to remove any debris from plughole and discard all into a clinical waste sack.

7. Rinse pool with clean water.

8. Remove PPE into clinical waste and wash hands.

9. Put on clean PPE

10. After ChlorClean tablets have dissolved (8-10 minutes) pour approximately 4.5 litres into the pool (with plug in) and wash all inner surfaces thoroughly with a disposable cloth.

11. With the remaining 0.5 litre of the solution wash any outside areas that may have received contact during birthing and the cleaning process (e.g. taps, handles grab rails, etc).

12. Discard any remaining solution into the pool and drain completely. Rinse out the pool thoroughly with plenty of clean fresh water. Be careful to wash off any exposed metal parts with clean water and dry the pool and surrounding area with paper towels.

13. Remove PPE into clinical waste and wash hands.

Appendix 2

Decontamination Procedure for Portable Birthing Pools

Cleaning Prior To Use

1. Wash hands prior to any decontamination procedure.

2. Always wear protective gloves and an apron (PPE).

3. Run the taps for 5 minutes to waste if the taps have not been used in the preceding three days, ensuring that the hot water tap attains temperature.

4. Clean the pool permanent liner with detergent solution (soapy water), rinse with tap water and dry with paper towels.

5. Fix the disposable liner in place, ensuring that the permanent liner is fully covered.

6. Fill the pool according to birthing pool protocol using single use hose(s).

7. Dispose of PPE and filling hoses into clinical waste and wash hands.

Cleaning and Disinfection after Use

1. Wash hands prior to any decontamination procedure.

2. Always wear protective gloves and an apron (PPE). Use facial protection if necessary. Ensure good ventilation.

3. Check expiry date on product. (see base of ChlorClean container)

4. Make up a ChlorClean solution in the ratio of 1 tablet to 1 litre of water from the cold tap. (This dilution makes a 1,000 ppm available chlorine solution).

5. Remove gross soiling from the water using single use sieve and discard into a clinical waste sack.

6. Drain the pool using single use hoses and pump into sluice/toliet

7. Remove the disposable liner and dispose in clinical waste

8. Remove PPE into clinical waste and wash hands.

9. Put on clean PPE.

10. After ChlorClean tablets have dissolved (8-10 minutes) wipe the permanent liner thoroughly with a disposable cloth.

11. With the ChlorClean solution, disinfect all outside areas that may have received contact during birthing and the cleaning process (e.g. taps, handles grab rails, stepping stool etc).

12. Rinse the permanent liner with tap water. Be careful to wash off any exposed metal parts with clean water and dry the permanent liner and surrounding area with paper towels.

13. Submerge the pump in a bucket of Chlorclean solution to disinfect the external surfaces and turn the pump on to disinfect the internal workings until all the Chlorclean has run to waste

14. Submerge pump in clean water to rinse the external surfaces and turn the pump on to rinse the internal workings free of chlorine. Run until all the water has run to waste.

15. Remove the pump from the rinse water, dispose of the hose into clinical waste, drain and dry the pump.

16. Discard any remaining solutions in the sluice.

17. Remove PPE into clinical waste and wash hands.

Appendix 3 NCL Birth Centre Acceptance Criteria 2012

|GREEN CRITERIA |AMBER CRITERIA |RED CRITERIA |

|All these women will be accepted onto the Birth Centre across|These women will require additional input from an Obstetrician and/or Consultant Midwife and all|These women should not be accepted into any birth centre across |

|the NCL Maternity and Newborn Network |other appropriate specialists. These women must have a birth plan which demonstrates this |the NCL Maternity and Newborn Network |

| |input. There must also be documented evidence that all risks have been discussed in partnership| |

| |with the woman and been understood. Acceptance will be decided by the individual Trusts within |These women will be under the care of an Obstetrician |

| |the NCL maternity Newborn Network | |

|Maternal age >18 and < 40 years |Maternal age 40 years |BMI > 35 or 18 and < 30 at booking |BMI 30 – 30.4 with no complications; assessment at 36 weeks to include weight gain |Multiple pregnancy |

|Hg 10g / dl at 36 weeks |Haemaglobin below 10g/dl |Breech/Unstable lie |

|Women who speak and understand English |Women who have limited English or other communication issues the availability and use of |Haemaglobinopathies |

| |interpreters should be considered | |

|Pregnancy normal throughout – risk assessment at booking, 28 |Other factors affecting the current pregnancy |Significant maternal cardiac disease |

|weeks & 36 weeks gestation | | |

| |Para 5 or more |Hypertensive disorders |

| |Recreational drug use. This should be evaluated in light of neonatal after care. |Significant respiratory disease |

| |Social factors that may impinge upon the birth e.g. domestic violence. The safety of the women |Immune thrombocytopenia or other platelet disorders |

| |and staff in the unit should be considered | |

| |IVF pregnancy |Bleeding disorders in the woman or fetus |

| |Asthma |Placenta praevia or accrete |

| |Epilepsy |Atypical antibodies that carry the risk of haemolytic disease of |

| | |the newborn |

| |Small fundal/upper uterine fibroids |Hepatitis C |

| |Declining blood products |Active viral infection: HIV, chicken pox, rubella, genital herpes |

| | |in the woman or fetus |

| |Increased risk of Down’s Syndrome |Active tuberculosis under treatment |

| |Neurological disorder; an individual mobility assessment is required |Active systemic lupus |

| |Hepatitis B |Scleroderma |

| |HIV if viral load undetectable |Renal failure or previous treatment for this |

| |Sexually transmitted disease |Diabetes including gestational diabetes |

| |Thyroid disorders |Abnormal renal function |

| |Low Risk Induction |Epilepsy |

| |Previous Pregnancy complications |Myasthenia gravis |

| |Previous C-Section |Liver disease with abnormal function |

| |Neonatal death with a known non-recurrent cause |Psychiatric disorders requiring inpatient care and on medication |

| |Group B Streptococcus (a process for antibiotics in each unit is in place) |Current pre-eclampsia |

| |Previous pre-eclampsia |Significant drug use |

| |Previous placental abruption with a good outcome |Significant social concerns e.g. removal of baby without mother’s |

| | |knowledge |

| |Previous poor mental health – not psychosis |Classical caesarean section |

| |History of previous macrosomia of 4.5kg + |Previous eclampsia |

| |Non-severe spinal or pelvic injury |Previous psychosis, schizophrenia or bipolar disorder |

| |Extensive vaginal, cervical &perineal trauma (3rd/4th degree tear) |Fetal complications |

| |Previous birth of a baby with jaundice that required exchange transfusion |Known fetal growth restriction |

| |Previous retained placenta |Major fetal abnormalities |

| |Women who have FGM | |

| |Previous shoulder dystocia | |

| |Fetal complications | |

| |Minor fetal abnormality | |

References:

Alderdice F, Renfrew M, Marchant S, Ashurst H, Hughes P, Berridge G (1995) ‘Labour and birth in water in England and Wales’. British Medical Journal. 310, (6983), p.837.

Burns E (2001) ‘Waterbirth’. MIDIRS Midwifery Digest (Supplement 2). 11, S10-13

Cluett ER, Nikodem VC, McCanbdlish RE, Burns EE. Immersion in water in pregnancy, labour and birth (Cochrane Review). In: The Cochrane Library, Issue 3, 2004. Chichester, UK: John Wiley& Sons, Ltd.

Cluett ER, Pickering R, Getliffe K, Saunders NJ St George (2004) ‘Randomised controlled trial of labouring in water compared with standard of augmentation for management of dystocia in first stage of labour’. British Medical Journal. 328, (7435), p.314-317

Crow S, Preston J (2002) ‘Cord snapping at waterbirth delivery’. British Journal of Midwifery. 10, (8), p.494-497

Eriksson M, Mattson L-A, Ladfors L (1997) ‘Early or late bath during the first stage of labour: a randomised study of 200 women’. Midwifery. 13, (3), p.146-148

Garland D, Jones K (1997) ‘Waterbirth: updating the evidence’. British Journal of Midwifery. 5, (6), p.368-373

Gilbert RE, Tookey PA (1999) ‘Perinatal mortality and morbidity among babies delivered in water: surveillance study and postal survey’. British Medical Journal 319, (7208), p.183-187

Gilbert RE (2002) ‘Water Birth - A Near-Drowning Experience’. (Letter) Pediatrics. 110, (2 Part 1), p.409

Hall SM, Holloway IM (1998) ‘Staying in control: women’s experience of labour in water’. Midwifery. 14, (1), p.30-36

Johnson P (1996) ‘Birth under water - to breathe or not to breathe’. British Journal of Obstetrics and Gynaecology. 103, (3), p.202-208

MIDIRS. (2003) ‘The use of water during childbirth’. Informed choice for professionals leaflets. [online] MIDIRS: Bristol. Available from: . [Accessed 04/01/06].

National Institute For Clinical Excellence (2007)

Intrapartum Care for the healthy pregnant woman and baby during childbirth. Clinical Guideline 55. [online]. London: NICE. Available from: .

Richmond H (2003) ‘Women’s experience of waterbirth’. Practising Midwife. 6,(3),p.26-31

Waldenstrom U, Nilsson C-A (1992) ‘Warm tub bath after spontaneous rupture of the membranes’. Birth. 19, (2), p.57-63

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Please see North Middlesex University Hospital’s NHS Guidelines

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