Water use during labour and birth - Safer Care Victoria



February 2020Water use during labour and birthClinical guidanceFOR CONSULTATIONTo receive this publication in an accessible format phone 03 9096 1384, using the National Relay Service 13 36 77 if required, or email maternityclinicalnetwork@safercare..auAuthorised and published by the Victorian Government, 1 Treasury Place, Melbourne.? State of Victoria, Australia, Safer Care Victoria, February 2020.Available at Safer Care Victoriasafercare..au Macrobutton NoMacro DefinitionFor the purpose of this guidance, unless otherwise stated, the following definitions apply:Water use: Use of water in a shower, a bath, a fixed or inflatable birthing pool, during the first stage of labour.Water Birth: Birth where a baby is born fully submerged in water.A qualified practitioner: a registered midwife experienced in the use of water for labour and / or birth in water.DefinitionFor the purpose of this guidance, unless otherwise stated, the following definitions apply:Water use: Use of water in a shower, a bath, a fixed or inflatable birthing pool, during the first stage of labour.Water Birth: Birth where a baby is born fully submerged in water.A qualified practitioner: a registered midwife experienced in the use of water for labour and / or birth in water.0000IntroductionWith growing evidence supporting benefits of water use during labour and birth, Victorian women are increasingly choosing to explore it as a pain management option. This guidance provides practical advice for Victorian maternity and neonatal care providers, as well as private midwives, who are supporting women considering using water during labour and for birth.Water use for pain management during labour and/or birth has been found to have numerous benefits, including a decreased use of epidural analgesia, a reduction in the length of the first stage of labour and an overall satisfaction with the birthing experience.1,2There is no robust evidence that demonstrates increased adverse effects for the woman or the baby.1,2,3Concerns have been documented in relation to potential adverse neonatal outcomes, including water aspiration, increased infection and a generalised increase in morbidity and mortality.3 However, large meta-analyses of randomised controlled trials and comparative studies (both prospective and retrospective), demonstrate that when midwives and medical staff are adequately trained and follow evidence based guidelines, there is no evidence to suggest that using water for pain relief in labour and the practice of waterbirth in a low risk population of women, is harmful to the neonate.1,2,3,4Numerous national and international peak bodies, plus many health services across Australia endorse and recommend the use of water for labour and birth. However, it should be noted that some of the recommendations are consensus views and are not based on robust research.5-11 Health services and practitioners are encouraged to ensure that women have the option for using water for labour and birth, and that they are able to make informed decisions about whether this is a preferred and safe choice for them.5-11Governance requirementsHealth services and practitioners are governed by state and national frameworks and standards for practice (see Appendix 1).Health services should provide planned care to pregnant women using a risk management approach that establishes when advice, referral, or transfer is required. This is to ensure that the right care is offered in the right place, at the right time and aligns with the Capability Framework for Victorian Maternity and Newborn Services. If the level of care that is required falls outside the capability of the health service, then consultation, referral and transfer processes need to be enacted, taking into consideration geographical boundaries, weather and road conditions. For health services, consultation with the State’s Paediatric, Infant and Perinatal Emergency Retrieval service (PIPER) should occur if emergency referral or retrieval is required. PIPER: 1300 137 650.au/piperDocumentation should be objective, factual, comprehensive and contemporaneous.Shared decision makingInformation on any potential risks and the benefits of water use should be provided to a woman early in the pregnancy. This is an opportunity to discuss and assist her to make an informed decision on whether water for labour and birth an appropriate and safe option for her. It is important that the information conveyed is understandable and culturally appropriate.During these discussions, it is important to highlight that plans may need to change either during pregnancy or in labour, if circumstances arise that necessitate the need to transfer out of the water. These discussions also should include the advice to leave the water if an opioid or epidural analgesia is requested. Some Health Services/qualified practitioners may opt to ask the women to sign a consent for birth in water.It should also be noted that very occasionally while using water during labour, an unplanned birth in the water may occur. Women and qualified practitioners should discuss and be aware of this possibility.Discussions regarding other aspects of labour and birth including consent for the third stage of labour management, should be documented in the woman’s health record. More information can be found in the Care during labour and birth guideline. Water birth at home Preparation for a home water birth should include an assessment of a suitable environment for a home water birth, including access to hot running water. The delivery of any supplies and equipment prior to 37 weeks pregnant, is advisable. Discuss the optimal pool placement site, evacuation procedure, clearing electrical equipment in proximity to the pool, adequate hot water tank capacity and encourage the family to fill the pool prior to its use, but only on the day of labour to avoid waterborne opportunistic infections.12 Water birth at home Preparation for a home water birth should include an assessment of a suitable environment for a home water birth, including access to hot running water. The delivery of any supplies and equipment prior to 37 weeks pregnant, is advisable. Discuss the optimal pool placement site, evacuation procedure, clearing electrical equipment in proximity to the pool, adequate hot water tank capacity and encourage the family to fill the pool prior to its use, but only on the day of labour to avoid waterborne opportunistic infections.12 Planning for water use The qualified practitioner(s) should always provide a safe working environment by maintaining effective work practices, adopting local procedures and practices and those that comply with the relevant legislative requirements within the Work Health and Safety Act.Training and experienceQualified practitioners must be appropriately trained and experienced in the use of water for labour and birth and practice in accordance with local health service policies.Health services should support practitioners who wish to gain experience in the use of water for labour and birth by facilitating access to training opportunities. There is however insufficient evidence to recommend a separate accreditation process.13Qualified practitioners must be aware of the correct procedure to assist the women to leave the water in an emergency, according to individual hospital guidelines or through risk mitigation in a home birth situation.What equipment is needed?In addition to standard equipment made available for birth, the practitioner should ensure that the following items are available for a first stage labour and/or birth in water: appropriate lifting equipment such as a net or sling for emergency evacuation of the poolappropriate oxygen and suction devices for both mother and babywater thermometer waterproof Dopplerwaterproof continuous cardiotocograph monitoring (if indicated and available) gloves of sufficient length to cover bare skin when in contact with water containing body fluids waterproof gown or aprondisposable liner for an inflatable pool a sieve to remove faecal contamination kneeler pads, cushions, low stool or birth ball for the health and safety of midwives and birth companion resuscitation equipment able to be brought to the pool sidehandheld mirror (single use, able to be appropriately cleaned or the woman’s own) directable light sourceadditional aids to consider are a shower hose over a pool, an inflatable neck collar or floatation devices.Health and SafetySpillages should be wiped and dried as quickly as possible. Cautionary advisory signs should be placed near any spills to alert staff, patients and visitors of any potential dangers. non-slip footwear must always be worn. the floor should be structurally strong enough to support the weight of the filled birth pool.it is advised that practitioners use kneeling pads and/or a stool to protect their knees and back and avoid prolonged periods of sustained awkward posture/s. attempt to keep a straight back when auscultating the fetal heart rate (FHR) or when assisting the birth if required.the woman may be asked to come to the side of the birthing pool and raise her abdomen closer to the midwife for FHR auscultation. inflatable birthing pools used in the homebirth situation should be placed with an access space on at least 3 sides, for ease of evacuation.Infection precautionsPrinciples of infection control during the first stage labour and/or birth in water should be maintained in accordance with local policies and the National Health and Medical Research Council, Australian Guidelines for the Prevention and Control of Infection in Healthcare (2019) (Appendix 1) In addition:the pool should only be filled at the commencement of labour.debris should be removed by the primary midwife prior to draining.initial rinse of the birthing pool should be performed by the primary midwife.the fixed pool should be disinfected as part of routine room cleaning.cleaning of inflatable birthing pools used in the homebirth program: inflatable birthing pool should be drained using a suitable hose, rather than manually with buckets.the inflatable birthing pool liner should be removed and disposed of with clinical waste.inflatable birthing pools should be cleaned with disinfectant wipes prior to deflating and then air dried before storing.when is water use a suitable option?The use of water should only occur when appropriate fetal monitoring is able to be undertaken. The RANZCOG intrapartum fetal surveillance guidelines advise that women who may require continuous electronic fetal monitoring during labour may still utilise water for labour, provided that adequate telemetry equipment is available.singleton pregnancyterm gestation (37+0 to 41+6 completed weeks gestation)no previous caesarean section or uterine surgerycephalic presentationfree from active infectious diseases (Hepatitis B, C and HIV)with a body mass index (BMI) <35 in early pregnancyphysically able to enter and exit a pool with minimal assistance appropriately grown babyhistory of previous shoulder dystocia (agrees to leave the pool when birth is imminent)history of postpartum haemorrhage (agrees to leave the pool when birth is imminent) confirmed macrosomia on ultrasound (agrees to exit the pool when birth is imminent) previous ante partum haemorrhage (not actively bleeding)ruptured membranes of <24 hours, with clear liquorno opioid analgesia received within 4 hours of entering the poolno epidural in situapyrexialwhen is Water use not a suitable option? previous shoulder dystociaprevious PPHconfirmed macrosomiaactively bleedingreceived opioidsmeconium stained liquorpyrexiaruptured membranes >24 hoursBirth pool informationThere is some evidence to suggest that progress of labour may be delayed if the woman enters the pool at a cervical dilation of less than 4cm. This has been described in the literature as increased rates of epidural and need for augmentation of labour.13 Conversely, there is also evidence to suggest water immersion can augment labour. Practitioners should use their clinical judgement and in partnership with the woman, decide when the optimal time to enter the water should be.11Water useDuring the first stage of labourOnly tap water should be used, without the addition of soaps or essential oils.The water level should reach the woman’s axilla or breasts when sitting.It is advised the water temperature should be monitored hourly and maintained between 36oC and 37.5oC to prevent hypo- or hyperthermia. The woman will guide practitioners as to a temperature that is comfortable for her. If her temperature exceeds 37.5oC it is wise to request that she leaves the water for a short while or until her temperature returns to normal.It is best practice for the clinician to remain with the woman at all times.Ensure adequate hydration is maintained by offering frequent drinks of water.A vaginal examination underwater can be undertaken if deemed necessary.Nitrous oxide and oxygen may be used while in the pool. The woman should be given appropriate instructions for safe use of this pain relief medication.During the second stage of labour A water birth occurs when a woman's body is immersed to the level of her axilla and her baby is born fully submerged into water. The baby’s head must remain submerged until after the body is born, then the baby should be brought to the surface immediately. Once born, the baby’s head must not be submerged again. The pool temperature should be maintained between 36.0°C and 38.0°C at the time of the birth.Encourage spontaneous expulsive urges. A mirror can be used to observe for external signs of progress if necessary.Support the woman with a ‘hands off’ birth with quiet, supportive verbal guidance, ensuring minimal stimulation of the baby underwater.Await spontaneous restitution and birth of the body.Ensure the baby is born completely underwater, with no air contact until being brought gently to the surface immediately after the body has birthed.If a woman raises herself out of the water during the birth, exposing the fetal head to air, she should remain out of the water for the remainder of the birth.Do not feel for the presence of a nuchal cord. If apparent and impeding the progress of birth, loosen the cord and disentangle as the baby is born. Under no circumstances should the cord be clamped and cut under water. Avoid excessive cord traction as the newborn is brought to the surface in order to minimise the risk of avulsion. Dry the newborn’s face and head. Skin to skin contact between the newborn and mother is encouraged, with only the newborn’s body submerged in the water. During the third stage of labourActive management of the third stage of labour is recommended. For this, the woman should be assisted to leave the water. Follow procedure as per Care during labour and birth. Do not administer the oxytocic injection under the water.Some women may choose to have physiological management of third stage of labour and consideration should be given for these women to remain in the water. They should understand the reasons why they may need to exit the pool and have active management commenced. If the woman chooses to re-enter the pool following completion of the third stage, the water temperature is maintained at 37-37.5oC and the room kept warm.Unless perineal trauma is assessed as severe or the woman is actively bleeding, any suturing required should be delayed for an hour following birth as perineal tissue may be water-logged and friable.14left161763Reasons the woman may be asked to leave the poolIf the pool becomes heavily contaminated, in order to clean or change the water.If contractions reduce or become ineffective and prolonged labour is diagnosed. (link to labour and birth guideline)If there are any concerns for maternal or fetal wellbeing.0Reasons the woman may be asked to leave the poolIf the pool becomes heavily contaminated, in order to clean or change the water.If contractions reduce or become ineffective and prolonged labour is diagnosed. (link to labour and birth guideline)If there are any concerns for maternal or fetal wellbeing.Care post birthSkin-to-skin contact between the newborn and mother is encouraged with only the newborn’s body submerged in the water. The mother should be kept warm following the birth.Newborn careIt is good practice to immediately dry the newborn’s face and head. Assessment of the baby should take place as per usual routines. Apgar scoring should not be delayed.Delayed cord clamping is recommended (see Care during labour and birth)If respirations have not commenced within one minute of birth, the cord should be clamped and cut, then the baby removed from the pool for immediate assessment and resuscitation. If remaining in the water, the temperature of the newborn should be monitored. The temperature of the water should be maintained at 36.5-37.5°C during this time.Consideration should be given to covering the baby with a towel and using the warm water to keep the towel warm, plus a dry hat, changing it if it becomes wet. The newborn should be dried quickly once leaving the water.Care of the mother in the first hour after birthThe water temperature should be maintained at 36.0-37.5°C while she remains in it. Consideration should be given to having warm towels and blankets when she exits the pool.If there is any evidence of maternal compromise including excessive blood loss, the woman must be assisted to leave the water immediately.The woman must be fully assisted when leaving the water.If perineal suturing is required, it is preferable to delay this until 1 hour after leaving the water, in the absence of excessive bleeding. This allows time for water retained in the tissues to dissipate following prolonged immersion. There does not appear to be high level evidence to support the exact timing of the repair.Appendix 1Maternity and newborn care should be provided in accordance with the following statewide and national frameworks, standards and guidelines:Australian College of Midwives (ACM) National Midwifery Guidelines for Consultation and ReferralAustralian National Breastfeeding Strategy: 2017 and beyondCapability framework for Victorian maternity and newborn servicesDepartment of Health and Human Services policy and funding guidelines (published annually)National Perinatal Mental Health Clinical Practice GuidelineNational Safety and Quality Health Service StandardsNational Strategic Approach to Maternity Services (NSAMS)Nursing and Midwifery Board of Australia (NMBA) Midwife Standards for PracticeRoyal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) Standards of maternity careVictorian Clinical governance framework National Health and Medical Research Council Australian Guidelines for the Prevention and Control of Infection in Healthcare (2019)References1. Cluett ER., Burns E. Cuthbert A (2018). Immersion in water in labour and birth. Cochrane Database Systematic Reviews 2018, Issue 5. Art.No.: CD000111. DOI:10.1002/14651858.CD000111.pub4. Available from: . Cluett, ER & Burns, E. 2009. “Immersion in water in labour and birth (Review)”, Cochrane Database of Systematic Reviews, Issue 2. [cited 17/2/17], available from . Thoeni, A, Zech, N, Moroder, L, Ploner, F (2005). Review of 1600 water births. Does water birth increase the risk of neonatal infection? J Matern Fetal Neonatal Med. 17(5): 357-61.4. Taylor, H, Kleine, I, Bewley, S, Loucaides, E & Sutcliffe, A. 2016. “Neonatal outcomes of waterbirth: a systematic review and meta-analysis”, Archives of Disease in Childhood. Fetal and Neonatal Edition, 101: pp F357-F365.5. Australian College of Midwives (2013). Position statement on the use of water immersion for labour and birth. Available from: . The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (2017). Warm water immersion during labour and birth. Position Statement. Available from (c-ob7. New Zealand College of Midwives Consensus Statement - The Use of Water for Labour and Birth 2015. Available from: . Department of Health, Western Australia. WA Water Birth Clinical Guidelines. Perth:Health Networks Branch, Department of Health, Western Australia; 2009. Updated February 2017. Available from ~/media/Files/Hospitals/WNHS/For%20health%20professionals/Clinical%20guidelines/OG/WNHS.OG.Waterbirth.pdfhealt9. The Royal Woman’s Hospital (2013) Water Birth at the Women’s (factsheet). Water Immersion for Labour and Birth. Available from . . National Institute for Clinical Excellence (2007) NICE Clinical Guideline 55. Intrapartum Care: Care of healthy women and their babies during childbirth. London: NICE12. Collins SL, Afshar B, Walker JT, et al. Heated birthing pools as a source of Legionnairres disease. Epidemiol Infect 2016;144:796–802.13. Cooper M, Warland J, McCutcheon H. Australian midwives views and experiences of practice and politics related to water immersion for labour and birth: a web based survey. Women Birth. 2017; . Garland D. (2011). Revisiting waterbirth: An attitude to care. New York, NY: Palgrave Macmillan 0000 ................
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