Key learning points:
– Water labour and water birth improves physical and psychological outcomes for childbearing women
– Water immersion during childbirth can impact positively on the wellbeing of newborns and increase job satisfaction for maternity caregivers
– Midwives have a professional duty to remain competent and confident in the skills necessary to facilitate water labour and water birth
Having a baby is the most common reason for admissions to hospitals in the UK.1 Maternity is unique within the NHS in that the midwifery services support predominantly healthy women through a natural, but very important, life event that does not always require intervention from medical staff.1
Midwifery philosophy describes childbearing as a normal, low risk process, with midwives as the coordinating or leading professionals for every birth.2,3 As such, the midwife must encourage as far as possible the normality of pregnancy, labour, birth and the postnatal period. As progressively more women with medical and obstetric complexities become pregnant, midwives are increasingly faced with the challenge of ensuring that normality is preserved even in high-risk pregnancies. Water labour and water birth (WLB) have proven popular and effective in helping midwives promote normality in childbirth.
Warm water immersion for relaxation and pain relief during labour and birth has a long history in clinical care.4 The use of water immersion for labour and birth has been available in NHS care settings in the UK since the 1980s.3 Medical and midwifery professional bodies all advocate offering the use of a birth pool to labouring women with uncomplicated pregnancies at term.3,5,6 The uptake of birth pools varies according to locality, size and the type of maternity care provider. Research indicates that between 30% and 79% of women use water immersion during their labour, with up to 71% of women labouring in a birth pool going on to give birth in the water.7,8 As many as 98% of water birthers would use a birth pool again, or recommend its use to other women.8
All maternity care providers should be able to offer WLB services.6 National guidelines recommend criteria for the use of a birth pool:5 an uncomplicated low risk pregnancy of at least 37 weeks’ gestation, established labour that progresses well, and reassuring maternal and fetal observations throughout labour. However, growing numbers of high-risk childbearing women with more complex obstetric and medical conditions are deciding to labour and give birth in water, without adverse outcomes.6,9-11
What happens in water labour and water birth?
Water labour involves immersion in warm water in a birth pool during established labour, which is defined as the onset of regular painful uterine contractions and progressive cervical dilatation from four centimeters.5 Labourers may prefer to come out of the water for the second (pushing) stage of labour, or they may wish to give birth in the pool. Women may opt for WLB in a free-standing or alongside midwifery unit, in a hospital-based obstetric unit, or at home with a NHS or independent midwife. Most maternity labour areas provide a plumbed-in birth pool, and portable water pools can be hired for use at home. Birth pools are wider than standard baths and at least two feet deep, so that a labouring woman can move easily while keeping her abdomen immersed in water.
The labourer may choose to be naked, or to wear swimwear or light clothing in the birth pool, and she may adopt any safe, relaxing position. The ambient room temperature should be comfortable, and the woman should drink plenty of fluids to prevent dehydration.6 A water labourer may wish for her birth partner or partners to join her in the birth pool, although many NHS institutions discourage this practice based on health and safety and infection control policies.6 Entonox inhalation analgesia (known as ‘gas and air’) is often used by women in the birth pool. The birth pool should not be used within two hours of opioid administration or following epidural anaesthesia.5
It is essential that the midwife frequently reviews the wellbeing of both the labouring woman and her baby. The labourer’s pulse, temperature, blood pressure and frequency of passing urine can be checked regularly, and the fetal heart rate (FHR) can be monitored intermittently underwater using a handheld Doppler device.3,5 If available, wireless telemetry can be used if continuous cardiotocographic monitoring is required.5 National guidelines recommend that the FHR should be auscultated after a contraction for at least one minute,5 every 15 minutes in the first stage of labour and every five minutes in the second stage of labour. The maternal pulse should be palpated every 15 minutes to differentiate between the maternal and the FHR. Pre-labour rupture of membranes at term and/or group B Streptococcus do not preclude WLB.12 The necessary intrapartum antibiotic can be administered through an intravenous cannula inserted and removed again while the woman is out of the birth pool.
The midwife should regularly evaluate the progress of labour, which can be ascertained by considering the labouring woman’s behaviour, palpating abdominally for uterine contractions and fetal position and station, performing a vaginal examination at least every four hours with the woman either in or out of the birth pool, and assessing the effectiveness of pushing technique. However, many women9,11 choose to have WLB in order to avoid ‘the cascade of obstetric interventions’,13 and therefore may decline to have fetal, maternal and labour progress observations performed as often. The midwife should support the labouring woman’s choices and document the alternative plan of care accordingly.5
Once the baby is born, the midwife, mother or birth partner can help to guide the baby gently, face first to the water’s surface, being careful not to pull on the umbilical cord. The feeling of air on the baby’s skin and a change in temperature then triggers his/her breathing reflex. National guidelines recommend clamping the umbilical cord between one and five minutes after birth.5 Delayed cord clamping allows the baby to continue to receive oxygenated blood from the placenta, increasing early haemoglobin concentrations and iron stores in newborns.14 Once clamped, the umbilical cord can then be cut by the midwife, mother or birth partner. The midwife and the labouring woman will have agreed upon either a physiological or actively managed third (placental expulsion) stage of labour. Active management at this stage in a water birth would comprise the intramuscular administration of oxytocin just before the umbilical cord is clamped and cut, with controlled cord traction to aid the delivery of the placenta.5 Minimal research exists on water immersion for the third stage of labour.4 Nevertheless, most maternity care providers encourage women to leave the pool for the delivery of the placenta, both for hygiene reasons and to assess post partum blood loss more accurately.
Potential complications of water labour and birth
There is no link between WLB and neonatal morbidity and mortality.3-6,8 The main concerns raised with water immersion for labour and birth include neonatal infection, the baby aspirating water at birth, neonatal hypoxia due to hyperthermia of the mother and subsequently the fetus during labour, and neonatal hypothermia after birth.4-6 However, adherence to national guidelines and local protocols ensure that labouring and birthing in water remains safe and effective.3-6,10 Quality assurance measures are important, namely protocols for birth pool cleaning, and infection control procedures such as filling the birth pool only at the time of labour, and maintaining water cleanliness as far as possible.3,6 During birth, once the baby’s head is visible, encouraging the woman not to raise herself out of the water and expose the fetal head to air alleviates the risk of water aspiration.3,6 The temperature of the birth pool water should be monitored hourly to ensure that it does not exceed 37.5°c, which could cause fetal hyperthermia and hypoxia.5 After the birth of the baby’s body, ensuring that the baby’s head is above water, but that the body remains submerged, prevents neonatal hypothermia as well as facilitating skin-to-skin contact and breastfeeding if the mother wishes.3
Potential complications for the woman labouring in water have been suggested to include a decrease in the frequency and strength of uterine contractions thereby prolonging labour, maternal hyperthermia, difficulties getting the woman out of the pool during obstetric emergencies, and inaccuracy in assessing blood loss.10 Again, effective midwifery care addresses such issues. The labouring woman can be encouraged to leave the pool for a while to mobilise, pass urine, rehydrate and try a snack if her uterine contractions are becoming less effective, or if she becomes too hot.3 The midwife can regularly monitor the woman’s and baby’s wellbeing, and ask the labouring woman to leave the birth pool if at any point the woman’s or baby’s vital signs become non-reassuring.5 The pregnant woman can be briefed antenatally on the importance of getting herself out of the pool quickly and safely if an obstetric complication such as meconium stained liquor arises, or an obstetric emergency such as shoulder dystocia or intra-/postpartum haemorrhage occurs.6
Potential disadvantages for caregivers facilitating WLB have been reported to include staffing problems, fear of obstetric emergency, and physical discomfort or injury.17 These concerns can be dealt with on an institutional level by guaranteeing that maternity services have the capacity to provide women in established labour with well supported, one-to-one midwifery care.5 On a professional level, all midwives are duty-bound to ensure that they remain competent and confident in caring for a woman labouring and birthing in water. Furthermore, all maternity caregivers are required to keep themselves up-to-date with local and national policies and protocols relating to not only WLB, but also to moving and handling, infection control and health and safety issues.3,6
Benefits of water labour and birth
Midwifery philosophy regards the concept of salutogenesis as fundamental to maternity care.3 Salutogenesis focuses on health and how to promote it, rather than on the traditional medical emphasis on risks, ill health and disease.15 Maternity care during pregnancy, labour, birth and the postnatal period should therefore be based on health factors, as opposed to risk factors,16 with the emphasis on normality.3
WLB improves physical and psychological outcomes for labouring women,3-11,17 and may impact positively on the wellbeing of newborns and the professional satisfaction of maternity caregivers.17 The physical benefits of WLB include easier maternal mobilisation due to the buoyancy of water, a reduction in the length of the first stage of labour, and less need for pharmacological pain relief.3-6,9-11,16 Psychological advantages for labouring women involve heightened comfort and relaxation, and an enhanced sense of choice, control and involvement in decision-making.3,9-11 Many advocates of water birth believe that being born into water allows the newborn baby to make a more gentle transition to life outside the womb.11 Benefits to maternity caregivers include the acquisition of new midwifery skills, as well as the opportunity to empower women and facilitate holistic, individualised, woman-centred care.17 Moreover, using water immersion during labour and birth helps midwives to support childbearing women exercising their right to informed choice and control, principles that underpin midwifery care.3
Labouring in water can reduce the need for pharmacological analgesia and reported maternal pain without adversely affecting maternal and neonatal wellbeing.3-6,10,17 Immersion in warm water also enhances women’s reported relaxation and satisfaction with pain relief.3-6,9-11,16 WLB heighten a woman’s sense of choice and control, which promotes increased satisfaction with the whole childbirth experience, not just for women and their birth partners, but also for midwifery caregivers.3,6,10,17 Although criticism exists that WLB could increase the risk of morbidity and mortality to a mother and her unborn/newborn baby, the empirical reliability and validity of these claims is lacking.4,10,12,18 Appropriate local and national practice guidelines and policies can help to address such potential issues.3-6,17
The National Institute for Health and Care Excellence (NICE) proposes that women be assisted to make an informed choice to their preferred method of birth, in consultation with the relevant healthcare professionals.19 Women can only exercise valid informed choice if they have access to current, reliable evidence about the practicalities and implications of the various different childbirth options. However, failings in the present maternity care service have been highlighted with regard to the availability, accuracy and consistency of information giving and shared decision making processes.7,9,11 Perhaps for this reason, together with the relative scarcity of current research into the practice of WLB, women are increasingly using internet discussion forums to access other women’s personal, anecdotal evidence relating to water immersion during childbirth.17 Further qualitative and quantitative research is therefore needed into the WLB services offered throughout the UK. Future research projects would contribute new information about existing WLB practices, and impact upon the maternity care given within the NHS on a personal, professional, and institutional level. Further research must be undertaken with a view to improving the WLB service as a whole, and to provide a clearer picture of the inequalities in the maternity service offered on a regional and national level.
1. National Audit Office. Maternity services in England, 2013. nao.org.uk/2013-maternityservices (accessed 30 July 2015).
2. Midwifery 2020. Midwifery 2020: Delivering Expectations.
dhsspsni.gov.uk/midwifery_2020_executive_summary.pdf (accessed 1 September 2015).
3. Royal College of Midwives (RCM). Evidence Based Guidelines for Midwifery-Led Care in Labour: Immersion in Water for Labour and Birth. London: RCM; 2012.
4. Cluett E, Burns E. Immersion in water in labour and birth (Review). Cochrane Database of Systematic Reviews, 2011. cochrane.org/CD000111/PREG_immersion-in-water-in-labour-and-birth (accessed 30 July 2015).
5. The National Institute for Health and Care Excellence. Intrapartum care: care of healthy women and their babies during childbirth, 2014. nice.org.uk/Guidance/CG190 (accessed 30 July 2015).
6. Royal College of Obstetricians and Gynaecologists/Royal College of Midwives. Immersion in water during labour and birth. Royal College of Obstetricians and Gynaecologists and Royal College of Midwives Joint Statement No. 1. London: RCOG; 2006.
7. Care Quality Commission (CQC). National findings from the 2013 survey of women’s experiences of maternity care. cqc.org.uk/sites/default/files/documents/maternity_report_for_publication.pdf (accessed 30 July 2015).
8. Baxter L. What a difference a pool makes: making choice a reality. British Journal of Midwifery 2006;14(6):368–373.
9. McKenna J, Symon A. Water VBAC: Exploring a new frontier for women’s autonomy. Midwifery 2013;30(1):20–25. ncbi.nlm.nih.gov/pubmed/24225432 (accessed 30 July 2015).
10. Garland D. Is Waterbirth a ‘safe and realistic’ option for women following a previous caesarean section? Completion of a three year data study. MIDIRS Midwifery Digest 2006;16(2):217−220.
11. McKenna J. Vaginal Birth After Caesarean Section: Exploring Women’s Experiences of Water Labour and Water Birth (Water VBAC). MSc thesis. University of Dundee; 2012.
12. Plumb J, Holwell D, Burton R, Steer P. Water birth for women with GBS: a pipe dream? Practising Midwife 2007;10(4):25-8.
13. Chalmers I. Obstetric practice and outcome of pregnancy in Cardiff residents, 1965–1973. British Medical Journal 1976;1:735–738.
14. McDonald S, Middleton P, Dowswell T, Morris, S. Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes. Cochrane Database of Systematic Reviews 2013, Issue 7. DOI: 10.1002/14651858.CD004074.pub3/otherversions (accessed 30 July 2015).
15. Lindström B, Eriksson M. Salutogenesis. Journal of Epidemiology and Community Health 2005;59:440–442.
16. Day-Stirk F, Palmer L. The Royal College of Midwives virtual institute for birth: promoting normality. RCM Midwives 2003;6:64–65.
17. Garland D. Exploring carers’ views and attitudes towards the use of water during labour and birth. MIDIRS Midwifery Digest 2011;21(2):193–196.
18. Young K, Kruske S. How valid are the common concerns raised against water birth? A focused review of the literature. Women Birth 2013;26:105–109.
19. The National Institute for Health and Care Excellence. Caesarean Section, NICE CG132. London: NICE;2011.
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