Guideline for a Safe Water Birth

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Guideline for a Safe Water Birth
© 2005 Barbara Harper - Waterbirth International

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.

Rationale
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.

Evidence

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

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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.

Eligibility

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 Defined

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.

When to enter the bath in labor

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 lead 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

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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."

Summary of benefits for labor and birth in water

Facilitates mobility and enables the mother to assume any position which is
comfortable for labor and pushing
Speeds up labor
Reduces blood pressure
Gives mother more feelings of control
Provides significant pain relief
Promotes relaxation
Conserves her energy
Reduces the need for drugs and interventions
Protects the mother from interventions by giving her a protected private space
Reduces perineal tearing
Reduces cesarean section rates
Is highly rated by mothers - typically stating they would consider giving birth in
water again
Is highly rated by midwives
Encourages an easier birth for mother and a gentler welcome for baby



Theoretical Potential Disadvantages
Decrease in uterine contraction strength and frequency, especially if entering
the bath too soon
Neonatal water aspiration
Maternal hyperthermia may contribute to fetal hypoxemia
Neonatal hypothermia
Cord immersion in warm water may delay vasoconstriction, increasing red cell
transfusion to the newborn and promoting jaundice
Blood loss estimation and assessment not accurate
Maternal and Neonatal infection may be increase - not supported by the
evidence
Risk of acquiring blood born infection or sustaining back injury for caregivers


Recommended Criteria for the use of a water pool

An uncomplicated pregnancy of at least 37 weeks gestation
Established labor pattern - good regular contractions
Reassuring fetal heart tones
Absence of bleeding greater than bloody show
Spontaneous or on-going labor after misoprostol or Pitocin






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Contraindications for birth in a water pool

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.

Absolute contraindications
Pre-term labor
Excessive vaginal bleeding
maternal fever> 100.4, or suspected maternal infection
Any condition which requires continuous fetal heart rate monitoring
Untreated blood or skin infection
Sedation or epidural
Fearful Attendant
Inflexibility in the client


Controversial contraindications

Meconium staining in amniotic fluid
The presence of meconium should be evaluated with fetal well-being not 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.
HIV, Hepatitis A, B, C, GBS
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.
Herpes
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.
Breech or multiple births
In the H. Surreys Hospital in Ostend, Belgium, frank breech is an indication for a
waterbirth. Their 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.
Induction or augmentation
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.
Intrathecal use
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.
VBAC
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

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women into the water because they don't provide waterproof continuous fetal
monitoring.

Shoulder Dystocia or Macrosomia with suspicion of Shoulder Dystocia
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)
Tight nucal cord
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.
Water temperature at time of birth
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.
Placental delivery in water
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.





Helpful reminders for the use of water immersion for labor and birth
Midwives should discuss the potential advantages and disadvantages of water
immersion for labor and birth with each woman prior to labor.
The fetal heart should be monitored according to accepted guidelines. Use of
a waterproof Doppler is recommended.
The woman should be encouraged to maintain adequate hydration and leave
the pool to urinate at regular intervals.
The woman should be asked to leave the water if there are any concerns
about her or her baby's well being.
The water should be kept as clean as possible. Stool and blood clots should
be removed from the pool immediately. The pool should be drained, cleaned
and refilled if contaminants cannot be easily removed.
A small amount of blood often looks like a lot. Undisturbed blood in a pool

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often congeals at the bottom of the pool into a small clot.
The pool or tub should be deep enough for the mother to assume any position
comfortably.
Encourage mother to help guide her own baby out.
Suturing may need to be delayed due to water saturation of tissues.
The baby should be born completely underwater with no air contact until the
head is brought to the surface, as air and temperature change may stimulate
breathing and lead to water aspiration. If a change in position during delivery
causes the baby to come in contact with air, the birth should be finished in
the air.
Care should be taken to avoid undue traction on the cord. There have been
reports of cord tearing.
The warm water helps maintain the newborn's temperature to prevent
hypothermia. Keep baby submerged with head out only for best heat
conservation. Next to mother is best.
Encourage breast contact immediately, but breastfeeding is not always
possible in the water, especially due to water high water levels.
You can insert a footstool or other object (husband) to raise a mother up high
enough after the birth.
Birth pools should be cleaned completely between uses with a chlorine-
releasing agent. All pumps and hoses should also be rinsed with bleach.
Outdoor hot tubs are OK to use for labor and birth, if they are cleaned and
maintained prior to the labor.
Jetted pools are ok to use if they are cleaned properly between patient use.
Small amounts of chlorine or bromine are not harmful to mothers or babies

As when caring for any mother or newborn, the midwife is responsible for using her
clinical judgment, responding appropriately to problems that may arise, and for
documenting her actions.


References

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

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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.


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