Waterbirth – Safety and Procedures

• General waterbirth resources
• Training for waterbirth
• When to get in the pool
• Water Temperature
• Hospital practicalities
• Can the floor take the weight?
• How long between birth of the head and the shoulders?
• Staying in the water after birth?
• Waterbirth and Midwives’ Back Injuries
• Links to other sources of information

General waterbirth resources

Does anyone have a nice document, reference, resource on water births generally?

There is very little water labour, water birth, research around (far more lucrative to do lots of research on drugs) but have you a copy of Water Birth Unplugged – the proceedings of the first International Water Birth Conference? It gathered together some of the most prestigious and informed names around the world, with case records and data on practitioners’ results and experiences. Ed. Beverley A. Lawrence Beech, Books for Midwives Press, 1996, ISBN 1-898507-53-8.

This book is available for £14.50 from AIMS on www.aims.org.uk

Beverley

The first International Water Birth Conference was inspirational to me and I have used much of the knowledge gained there since, including not cutting the cord around the baby’s neck in or out of water.

Kerri-Anne.

Just got in from a late shift and just felt I had to tell somebody about the wonderful birth I was at today. Second baby (ventouse last time) wanted to use the pool for delivery. I’ve never been present at one but reassured by labour ward manager that you do very little and she will come in for support at the end.

Once in the pool mum relaxed so much she actually dozed off. Lights down as much as they would go, battery-powered CD player on in the corner, lots of questions from mum about how would she know it was time, and what was the best position for me to see what was going on. Lots of reassurance from me to do what her body told her.

Only sign that she had started pushing was some gentle grunting from her. Knelt up leaning on side of pool pushed for 10 mins and wonderful slow delivery of a beautiful baby girl. Only thing I did was bring her to the surface while mum turned round to hold her. Afterwards mum said it felt so different to actually push a baby out of herself compared to last time when he was pulled from her.

Donna

A midwife came to the postnatal ward to ask the others if they were willing to conduct a waterbirth. Nobody asked me, but I volunteered and was grabbed!

05.15, I met the client and her partner, who were so grateful. She had been labouring in the bath for an hour until I arrived. CTG fine so into pool, and it was obvious that delivery was imminent. No drugs at all, except the water. SRM and the mirror showed the vertex at 06.05. At 06.07, a live boy was born and swam into his mothers arms, a true joy, the happiness was almost touchable!

5 minutes in water and mum asked to get out to deliver her placenta physiologically, which she did 17 minutes later with her son suckling to stimulate the procedure. Estimated blood loss approx 450mls, which was probably liquor too. I left a very happy family at 07.40 who were grateful that I had volunteered, and will take their son home today to meet his sister.

Supremely happy, I parked the car high on the downs on the way home and watched 2 hot-air balloons soar in the morning sky. Bliss. And I thought back to the beginning of the shift when I was so tired that I was ready to hand in my notice. Not now, there is nothing on earth to compare with the way I feel right now!!!

Elaine

I just needed to tell everyone about the wonderful waterbirth I had today. I stuck my neck out to give the woman what she wanted, against mumbling from other midwives and doctors who had put doom on it before it had started.

The birthing pool at our hospital is not very well used partly because we haven’t had it long and because many of the staff are unsure about it so they don’t use it, and for those of us who want to use it, we get very little support.

Anyway I admitted a primip at 39 weeks this morning (0730) who had SRM’d (spontaneous rupture of membranes) and was contracting 3:10. She was 4cm dilated, fully effaced with the presenting part at the spines. She wanted to labouring in water so I spoke to the co-ordinator who did not say no but she was not very enthusiastic. She entered the pool at 0845 (she was in the bath whilst the pool was filling as it takes a good hour), cont 4:10 strong and using entonox. Involuntary pushing at 1000, vertex visible at 1030 and a beautiful birth at 1046.

Physiological third stage, intact perineum and a 6 hour discharge, perfect! With the woman’s consent the co-ordinator and another midwife witnessed the birth and the talk of the delivery suite is this waterbirth, so hopefully the pool will get used a lot more. I’m so glad I stuck my neck out and gave this woman the opportunity to have the birth she wanted.

Louise

My personal feeling is that waterbirth is just like any other birth, just a bit more tricky for the midwife from a logistic and from the manoeuvring point of view. Most people will have heard it said that if humans were supposed to be born in water, we’d have gills and fins i.e. that water is not a natural medium for birth. I think that if one is used to births where interventions are used as routine no matter how small the intervention, then water can be a harder place for the midwife to get her head around doing a birth in. Some things are just harder to do when the woman is surrounded by water. Things like monitoring, cord cutting and assessing baby.

However if you are used to a hands-off approach then water really does show up how inconvenient interventions can be to the flow (I mean things like monitoring and perineal support and even actually receiving the baby into your hands)

If you are going to monitor and do perineal support and check for a cord around the neck, or even feel that you need to see the head and body emerging, be prepared to get wet and don’t even imagine that gloves with be the slightest bit of good as a barrier against getting blood on you! Comfort and familiarity come with experience so the first one does pose some questions.

There are special dopplers which are designed to work in water. Perhaps the trust will invest in one as it can be tiresome trying to get pinards, fetascopes and regular dopplers in the right position without getting them and yourself wet.

Sometimes depending on the woman’s position, it is hard to see when and how the head is emerging and if you are used to direct visualisation this can be uncomfortable for the midwife. Its rather like the first birth you saw in a squat. I can still remember being prone on the floor peering up so I knew where my hands were to go if needed. I now feel that most of the time my hands are not really needed and it is my need to ‘do something’ that keeps them hovering.

I will add however that there are births where I feel some perineal support is very appropriate. The birth of my own daughter is a fine example…Active labour was fast and furious, with no space between ctx and 3-7cm in 1 hr& 7-10cm in ten minutes. I pushed twice and the head was visible, and by the 3rd push my daughter was crowning. My midwife could not (short of climbing in with me) support the perineum and I did tear with the next expulsive force whereas I feel that in hindsight I could have done with some directive support and perhaps slowing down for the shoulders. This would have required my midwife to be more “in my face”. If I was having another labour like that I would probably choose to be in a different position and an easier medium for my midwife.

I have not found it to matter when the cord is cut and again this is really a discussion that could be about any birth, not just a water birth. Its simply that in the water this again is not the simplest of manoeuvres.

The main worry is how on earth does one assess blood loss in water therefore how do you know when there may be a need to cut the cord and begin active third stage management? Again, its a matter of getting used to what colour the water is with an “acceptable” amount of blood loss. Therefore it is advisable(reassuring) to have someone who feels comfortable and familiar with this. Failing that, have faith that you will know when there is a need to do something. It is as obvious as the difference between a baby with Apgars of four and Apgars of two: until you see it you cannot visualise it. Trust that you will know it when you see it.

If the mum plans to stay in the pool and coo at the baby rather than get out for the delivery of the placenta, make sure the room is hot as the cooler air can be chilling for the baby. This means heating it during third stage to a point which is uncomfortable for those outside the water, but also being able to cool it off a bit once mum and babe are out and dry. Logistically I have no experience in this as the waterbirths I attended all took place in the summer in Texas!

One last thing..some people have found that getting in the pool too early can relax labour too much and for that reason i think women should be made aware of this and encouraged to get in as their final comfort measure i.e. when active labour hits and they really feel they need it.

I do feel that sometimes women can have their minds very centred around wanting a waterbirth and focus in on it as the main attraction and for this reason might not wait for when their bodies tell them its time to utilise the pool as an aid. Water births can be so beautiful..the water makes this fluid almost languid in a way that surpasses dry land. I think that women who have read and seen pictures of water birth can sense this and are seeking a gentler way to birth their babies and this should be respected to the best of the midwives ability (and agility!)

Tania

Most people will have heard it said that if humans were supposed to be born in water, we’d have gills and fins i.e. that water is not a natural medium for birth.

There’s a lot along these lines in the Obgyn-net forums, eg the thread which starts from http://forums.obgyn.net/forums/ob-gyn-l/OBGYNL.9510/0147.html

Touching, this faith in evolution having designed the body perfectly to give birth! Shame those who bash waterbirth rarely ever apply it to other aspects of labour…

Consider the corollaries – we have been walking upright for hundreds of thousands of years, so where is the evidence in favour of supine birth? Our pelvises are designes for upright movement, after all. And if women had evolved to need routine syntocinon, we’d have convenient openings in our veins, or would be born with cannulas sited. And if nature wanted us to have epidurals, we’d be born with a needle sited.

Hey, why not go the whole Victorian hog and say that women are *supposed* feel pain in labour and it is just plain wrong to try to relieve it by any means.

Incidentally, if you read “The Aquatic Ape Hypothesis” by Elaine Morgan, there is some evidence suggesting that humans may have gone through a semi-aquatic phase at some point in our evolution. For example, among mammals only humans and aquatic mammals like otters and dolphins can consciously regulate their breath-holding according to the expected duration of submersion. There are also arguments that our vocal abilities and upright posture may be related to our ancestors having spent a lot of time in water. A controversial hypothesis, but interesting. Read the (short) book before you pooh-pooh it! Some think it explains why some people feel drawn to water when in a ‘primitive’ state, like labour.

Somewhere on the obgyn-net forum thread mentioned above, a midwife says that, since the baby has spent 9 months in water, she doesn’t see what the big deal is about keeping it there for a couple of seconds more….

On the other hand, one thing which does worry me slightly is the thought of hanging around in the water after the birth. I know that many women do this with no problems, but there was that case where a baby suffered severe over-transfusion of blood because the placental blood vessels stayed dilated in the warm pool after birth (see links). It seems to me that a few seconds from birth to surface in water are unlikely to make much difference to the baby, but once the baby is breathing air, maybe the water could alter the way third stage works in some cases. Any thoughts?

Angela

I do feel that sometimes women can have their minds very centred around wanting a waterbirth and focus in on it as the main attraction and for this reason might not wait for when their bodies tell them its time to utilise the pool as an aid.

This is one reason I chose not to hire a pool. Quite a few people assumed I’d be going for a waterbirth simply because I wanted a home birth. *For me*, it felt as though the pool would ‘take over’ and be the centre of attraction, we’d be thinking about filling it rather than doing whatever our thing happened to be at the time, I knew I was the kind of person who’d feel obliged to use it ‘cos we’d paid for it, but it mightn’t be where I wanted to give birth in the house.

Jennifer

Training for waterbirth

Could anyone tell me what sort of training in waterbirths is needed, for a midwife to be considered competent in ‘doing’ them?

Check foetal heart and maternal pulse/bp while in water (mum can lift tummy out of water if midwife doesn’t have a waterproof sonicaid, or a condom can be put over a normal sonicaid to waterproof it), and then sit on her hands and behave herself otherwise! If there are any problems, eg dodgy foetal heart rate, mum is usually advised to get out of the pool. Otherwise, what is there for the midwife to do? Lean in and catch baby if necessary, or take baby if mum hands it to her. Ask mum to stick her bum in the air if midwife needs to get her hands on (eg nuchal cord)?

Get mum and baby out of pool for third stage, or at least be aware of research on possible complications from staying in warm pool for a long time with an uncut cord?

Angela (not a midwife)

The average person will need to think about (all those) things before the event. It took some time for me to be convinced that babies wouldn’t drown!! We’re people as well as midwives. As for the condoms bit they are worse than useless! Very expensive when the water gets in, as I found to the trust’s cost. Pinard’s varnish stays put, so far, but I’m hoping that the longer one will be easier on mum and my back.

Midwives work within a regulated profession that is specific that the responsibility for attaining competence and remaining competent (Midwifery Rules) is with the midwife. She can self assess and if the work is very new to her i.e. water birth would do well to seek support from a suitable sensitive supervisor of midwives. Being an employed person is another matter! Some trusts have very nifty ways of trying to ensure life is as difficult as possible.

Waterbirth/care in labour is now part of midwifery training so some people have to play catch-up in relation to the role (Midwifery Code).

Heather

For many hospital midwives it’s a completely new concept being hands off and the first ones you are part of are not only amazing but terrifying too. At Edgware they have the system of see one do one (as long as all happy) and that’s now the policy in the Trust where I work. This time last year it was no to waterbirths but now with some training and discussion women are asking for them and m/ws appear more relaxed with the idea!!!

Please understand that yes midwives are in the main competent to do them, but trusts are very litagation-minded, and we are employees too.

Cate

There has been so much information written about birthing in water that any short literature search will give all the information necessary with minimum effort. I started caring for women using water in labour several years ago when the unit I was working in installed a pool. I saw one waterbirth carried out on a video and read all the information and guidelines and then I was ready to go.

It’s a ‘sit on your hands” approach but I like the fact that there is usually minimal interference in these births. I have been amazed at how well the water works for some women. My last unit had a pool but it was rarely used (a shame) and when on Labour ward I would often suggest it to women in labour, some used it and a few of those decided to deliver their babies into the water.

jadeamylucy

Before I left the NHS I did a half day of training re waterbirth. It looked at some of the physiological effects of being in water and how too high a temp can affect the baby and things to be aware of with mum. and stressing the inportance of making sure all temperature is monitored including room and water temperature being done hourly (on top of hourly maternal temp and pulse and BP). We then trouble-shooted with various senarios looking at different issues.

This was all done before I had seen a waterbirth, let alone assisted at one, and at the time it all seemed really complicated and a lot like too much to think about that takes you away from caring for the woman’s needs (I was told that if the pool wasn’t 37 degrees in the 2nd stage and we couldn’t get it up quickly to ask the woman to leave the pool which at the time made me think that it must have a really big effect half to 1 degree)

I am now in a job where most of my clients use water to help with their birth with many having their baby in water.

I have very quickly learned that it isn’t that difficult or complicated – I can now put my hand in a pool and know whether it is too hot too cold or just right and that the woman will soon tell you if the temp isn’t right. It is now the first thing I suggest when women are needing more relief from their contractions as it usually is blessed relief!!!!

I am quite a hands-off midwife when it come to the birth anyway, so just watching doesn’t feel too alien and the mums are usually so ready to meet their babies that getting babies to the surface is not an issue.

I have have had various “scary” moments during a waterbirth including a shoulder dystocia and an undiagnosed breech. In fact the first waterbirth I assisted was before my second midwife arrived!!!!

I have this growing feeling the training that midwives get (if anything like mine) is scaring a lot of those who are less inclined towards waterbirth off by making it seem really complicated and risky, rather that a really useful tool to help women. Most midwives encourage women to use the bath during labour, but as soon as a pool becomes involved it all becomes more complicated than it should be.

My waterbirth kit list is (in order of importance!):-

• A waterproof sonicaid – which incidentally raises the question as to why huntleigh thinks a waterproof probe and a unit that stops working if you splash even a little bit of water on it is a practical solution – I have more than once been at a birth where I have had get my second midwife out of bed to bring a dry sonicaid (I find using a pinard too intrusive at some labours)
• Torch and mirror (Torch is quite small and unobtrusive rather than million candle industrial size one I see in alot of hospitals!! and my mirror is a mirror tile from the bthroom dept of IKEA which should satisfy and health an safety worries as is has no nooks or crannys to breed bugs!)
• digital thermometor (mine is just a cheap one – you can check mum and water temp with it – I don’t check room temp – you would want it warm anyway)
• Change of clothes – I always get soggy arms and boobs and have on one occasion climbed in the pool to get better access!!!
• Some of my collegues use long gloves – I don’t.

I think training is important but doesn’t need to be intensive or heavy and just gaining experience is as good a thing as any. I suspect inexperiences midwives could provide care from a checklist of things to remember, but maybe I’m being a bit cocky there.

Gillian

(from a mother)

Personally I’d remain in the water regardless of the midwife’s experience because I’m confident enough in my own knowledge of the subject, and that I’d be able to get out if I needed to. Have always caught my own 4 babies in the water so that doesn’t worry me either.

It seems to me that the most important issues are:

• Safe temperature regulation, ie lower temp whatever is comfortable for mother, but don’t go above 37 – 38C
• Water hygiene if the water was not freshly drawn, ie check it’s not manky stuff that’s been sitting around untreated for a fortnight.
• Monitor with waterproof sonicaid or get mother to raise belly out of water to use normal sonicaid or Pinard.
• Get out if any suggestion of foetal distress in case baby gasps when born
• Baby either all in the water, or all out of the water, for birth – not part in, part out, in case sensation of air on body stimulates it to breathe early.
• If any complications once head is born (shoulders, tight nuchal cord) mother can stand up in the pool. Action of stepping out of pool apparently frequently resolves stuck shoulders.
• If baby born in water, bring to surface immediately and keep warm
• Be aware of issues regarding third stage in water and possible risk of overtransfusion of blood to the baby through dilated cord vessels.

Is there anything else which is important? Or which was covered in the training received by midwives on the list?

Angela

Pretty much everything you covered is what I was taught as a student midwife about waterbirth. This included a few teaching sessions in college and an extra study day for post reg midwives which my uni allowed us to attend.

Most Unis have regular study days (I think my uni had 2 a year) covering waterbirth – including practicalities of where you can get pools from, and covering Odents work. These are usually open to NHS midwives via trust/uni education contracts.

It tends to be the practicalities of obtaining actual experience of waterbirth, that are difficult. In 2 1/2 years as a student and midwife I nearly got to see one once. Although I feel I would be able to deal with a waterbirth if I had to – say a woman refused to get out of water and there were no other midwives available, I would feel more comfortable if I had a couple under my belt with an experienced midwife there.

We have a pool in one of the 10 delivery rooms at my trust, but I don’t think we manage to have many deliveries actually in it.

Sarah

When to get in the pool?

We do not recommend getting in the water until the cervix is 4cms dilated (ie if they are having V/Es!), because prior to that, it is thought to inhibit uterine activity. Once in established labour it is thought to enhance uterine activity (Odent, 1998; Anderson et al, 1996).

Ruth

Water Temperature

What is the best temperature for a birth pool?

About 36.5 – 37.5 C for the birth, but whatever is comfortable for the mother during labour, as long as it isn’t too hot as this can lead to exhaustion, blood pressure problems, and contractions may slow down. It has been suggested that if the water is too hot i.e. over 38.5 C this can cause problems for the baby. It is best to err on the side of caution and not have the water much higher than body temperature;, it could be uncomfortable and hard work for the mother at that temperature anyway.

The room temperature should also be comfortable for the mother – this may be cooler than the baby will need. After the baby is born and breathing established, the room should be quickly warmed up before the mother and baby leave the pool. Remember to drink fluids while you’re in the pool as you can get equally, and sometimes even more, dehydrated.

Sun – birth pool agent

According to our protocol, the recommended temperature is not to exceed 37 degrees at any time.

Hyperthermia in the fetus causes fetal distress (RCM, 1994; Brown, 1998).

First stage of labour: 36 degrees C

Second stage of labour: 37 degrees C

The temperature is tested: – hourly during 1st stage, quarter-hourly during second stage to ensure correct temperature temperature.

Ruth

Last year I did a lot of research into the optimal water temp for an assignment and with help from others on this list this is what I found :

Pool temperature is thought to be an important consideration for both mother and fetus. Fetal temperature is at least 0.5 degrees centigrade higher than the maternal temperature (Odent 2000) and as maternal temperature rises the basal metabolic rate and oxygen requirement of the fetus increases, thus if the mother becomes pyrexial the fetus may not be able to meet such an increased oxygen need. As the fetal thermoregulatory system is immature, an increase in fetal temperature can cause tachycardia leading to hypoxia that in turn may lead to severe fetal compromise and even death (Rosevear et al 1993). However, fetal tachycardia associated with maternal pyrexia can be resolved by cooling the mother (Deans and Steer 1995).Water temperature is also thought to be important during the second stage of labour as it is suggested that birth into warm water will not stimulate respiration in the same way as cold water would (Johnson 1996).

In guarding against fetal hyperthermia due to maternal pyrexia and in an attempt to prevent undue stimulation to the neonate at birth, suggestions have been made concerning optimal pool temperature. The Royal College of Obstetricians & Gynaecologists (RCOG 2001) recommend water temperature should not exceed 37C at any time but Deans and Steer (1995), Johnson (1996), and Garland (2000) suggest temperature should be 37.5C or below during the first stage and between 37C – 37.5C throughout the second stage. However, whilst there is an understandable rationale behind these suggested optimal temperatures it seems that the evidence on which they are based is derived from theoretical possibilities rather than actual evidence.

Deans and steer (1995) based their recommendation on an audit of 112 case records taken from 353 women who laboured or birthed in water. Fetal tachycardia was detected in five women, four of whom became pyrexial but pool temperature is not mentioned. Conversely, there was no maternal temperature recorded for the fifth woman but a water temperature of >38oc was recorded. This shows a clear association between maternal pyrexia and fetal tachycardia but does not show an association between pool temperature and maternal pyrexia as the pool temperature was not recorded in four out of the five women studied.

Furthermore Johnson’s (1996) conclusion that immersing a mother in water temperatures higher than her body temperature can lead to fetal hyperthermia is based on the findings of Deans and Steer (1995) . Therefore, current suggested optimal water temperatures are based on theories and opinions rather than empirical evidence and further research in this area is needed before such temperatures can be deemed optimal.

References:

Burns E and Kitzinger S. Midwifery Guidelines for use of water in labour, Oxford Brookes University

Beech BAL (Ed). Water Birth Unplugged, Books for Midwives Press, (also available from AIMS), Beech BAL. Choosing a Water Birth, AIMS,

BURNS, E,. 2001. Waterbirth. MIDIRS Midwifery Digest. 11 (3) supplement 2. S10 – S13

DEANS, A.C AND STEER, J.P,. 1995. Temperature of the pool is important (correspondance) British Medical Journal. 311 390 – 391.

GARLAND, D,. 2000. Waterbirth: an attitude to care. (2nd ed) Oxford: Books for midwives.

The RCOG (2001) recommend that temp should never exceed 37oc…….article can be found Royal College of Obstetricians and Gynaecologists – waterbirth recommendations(www.rcog.org.uk/medical/birth.html)

Julia

Two and half years ago, a client of mine got into the pool before I arrived – it was hot. Her temp after about 50mins in it was 37.8 and her baby’s heart rate 180 plus. I checked the obs (observations) about 20mins later and they were the same. I did not at the time comment on the temp particularly, but explained that I would like to perform a VE with her permission as I felt that she may have an infection. She lived 40 mins from hospital and it was December and snowing. She was 4cm, not fully effaced. I felt we should transfer to hospital because of the fetal tachy and temp of Mum. I was concerned with her birthing an ill baby/infected perhaps.

On arrival in hospital about an hour later, her temp was 36.5ish and the baby’s heart rate 157 or there abouts. I advise ladies that I would like them to wait before gettting into the pool until there is heavy show, and/or I am there, because it was such a shame that I felt that things MAY not be normal and transferred to ‘safety’s’ sake’. She proceeded to a lovely normal birth, and I came home with her 3 hours after the birth. All was well in the postnatal period too. There, my 25p’s worth

Deb

Some people think the whole question of water temp is a bit over rated as … some women in British Guyana giving birth in the sea – and I have seen the video of the Russian women who give birth in the sea….and this water is not heated…..although Johnson p (1996) Birth under water -to breathe or not to breathe British Journal of Obstetrics and Gynaecology 103(3): 202-20~ says that warm water is less likely to stimulate breathing in the baby and so cold water is not recommended.

Birth video of Russian births in black sea available through ACE graphics (www.acegraphics.com.au) called “Birth into being”. It certainly calls into question all our policies and procedures – you don’t see a third stage but also no-one seems to be in a rush to get out of the water after birth, in case of water embolism.

I have been in the Black Sea ( Greenham Common Women visit to USSR 1985) and it was bloody freezing and I really have a difficulty in believing women got into water at that temp let alone giving birth there!! I usually use a bit of common sense, and take the water temp occasionally and feel it quite often. In my experience the woman will ask for it to be made warmer or cooler depending on how she is feeling. I have to say I get a bit nervious if it is much more than 37.5 and ask for her to have it cooled down a bit particularly if she is getting on in labour. In early labour I don’t think it is too important. After all, women who could, have been getting into hot baths in early labour since Adam was a lad .

Mary

As I am a person who likes her baths at virtual boiling point, I spent some time in pregnancy quietly resenting the prospect of being harassed into having the water too cold in the pool at my homebirth. (I made a special effort in pregnancy to cool down my baths a bit as I appreciate the possibility of really excessive temps being a bad idea) Of course what I failed to take into account was the level of work a labouring woman’s body is doing, and the amount of heat it generates. I found that I wanted the water surprisingly cool for the first stage – and that I did want lots of drinks ( no different to a dry land birth for me in that). I would have been very cross then if anyone had tried to tell me that the temperture was “wrong” – one of the many joys of the water is the sense of privacy and having one’s *own* environment.

However, I know that my husband tipped in a bit of warm water during second stage – and I can’t remember if it was me or the midwife who suggested it. It was nice, though. If it wasn’t me who asked, does that mean that the midwife knew better? Actually, I guess if it hadn’t sounded like a good idea, I would have told him ( husband) to get lost (probably not at my most polite at that point). Once the babe was born, the water started to feel a bit chilly so I got out after a few minutes. Also didn’t want to share water with placenta. ( very grateful to marvellous placenta, very impressed with it’s wondrousness, but did not want to bath with it, not as nice as baby )

Brenda W

I have heard from a number of women who have had little benefit from their birth pools due to their midwives insisting on following guidelines for temperature which did not suit that woman. In one case, the midwife insisted that the pool temp should be 36 or 37C throughout, which for many women would be way too hot for the first stage. The mother felt hot and sick when she tried to use the pool, so she retired to the bathtub, where she was in control of the temperature. She felt cramped and unable to get in a good position, but at least she got the soothing benefit of warm water. She decamped to the birth pool for the second stage where she had a wonderful waterbirth of a first baby, at home.

I suspect that ths issues around waterbirth temperature sometimes get confused. As far as I can tell, these are the concerns:

1. During the first stage, the temperature should not be too high, as if the mother’s core temperature is significantly raised, this could harm the baby.
2. During the second stage, the worry is that if the baby is born into water and stays there for more than a second or so after birth (ie with any part of its body immersed), then the water should not be too cool, to stop the baby losing heat rapidly.
3. If the baby is born into water then some worry that if the temperature is significantly different from the mother’s body temperature, the baby might be stimulated to breathe while still underwater.

Here are my musings on each of these:

1. First Stage Temperature –

Concerns about overheating are discussed thoroughly in:
Fetal hyperthermia risk from warm water immersion, by Catherine Charles, British Journal of Midwifery, March 1998, Vol6, No 3, p152.
The author concludes that:

“Studies suggest an increase in maternal temperature to around 1.0C above baseline is unlikely to compromise a healthy fetus, and may even be beneficial. However, at a certain temperature benefits cease.. the fetus increases its metabolic rate and oxygen demands, producing increasing amounts of undisssopated heat with serious consequences” (p155-6).

It is not clear exactly how much a rise in water temperature will be reflected by a rise in maternal body temperature – studies on non-pregnant women have shown that in water of 39C the person’s body temperature will be at least 38C. Charles recommends that the temperature should be “no more than 37C for the expulsive stage”.

I had previously been very sceptical of all these upper limits on pool temperature, but having read the literature am more convinced. However, I remain entirely sceptical about lower limits!

The problem in first stage seems, anecdotally, to be not that women want to have the pool too hot, but that they may want it cooler than the ‘guide’ temperature. Many women actually want the water to be significantly cooler than blood temperature in the first stage. This makes perfect sense as being in warm water can make it hard to lose excess body heat. When you are in labour there is intense muscular exertion going on and you will be generating quite a lot of heat which you need to lose, just as if you were taking vigorous physical exercise. Note, for example, that in a leisure centre, fitness pools (ie ones designed for swimming lengths) are usually maintained at a lower temperature than leisure pools, where you just hang out! I believe that swimming pool temperatures are often around 28-29C for fitness pools, rising to 34C for hydrotherapy pools.

In water, the mechanism by which your body gets rid of excess heat is different to that on land. On land you can lose heat by radiation from your body, as well as by sweating. In water you cannot lose heat by radiation or by sweating from the parts which are underwater – only by conduction through the water, which is less efficient. Think of how it feels when you are having a very hot bath, or if you have ever tried to do serious exercise in a warm swimming pool. Your head (which can lose heat by radiation and sweating, and which makes the most of the opportunity!) feels hot and sweaty. Not something you really want in labour. As far as losing excess body heat is concerned, it is far harder to lose excess heat in water at 37C than it is in air at 37C. Now imagine trying to run a marathon at 37C – that’s what, 98F ? Would those temperatures help your performance?!!

I can understand the concerns about not having the water too hot in the first stage, but I cannot understand why some people try to maintain a minimum temperature in first stage as well. The mother’s comfort should be the only criterion for the minimum temperature.

During my first pregnancy I attended a waterbirth workshop where partners were warned that, if they stuck their hands in the water during the first stage, it would probably feel very cool, and they should not try to ‘help’ the woman by warming it up unless she requested it!

Catherine Charles’s recommendations for pool temperature (in her 1998 article cited above) are:

“Water temperature should be kept as cool as the woman finds comfortable during the first stage of labour, and increased to no more than 37C for the expulsive stage”, and that maternal temperature should be monitored throughout labour. (p155)

2. Second stage

Most women want the water to be warmer in second stage, anecdotally – personally I found it helped to soothe sore muscles. But if the temperature has not quite made it to the midwife’s preferred levels, or the second stage is rapid – surely the mother and baby could just get out straight after the birth? It would help to have a blow heater or something which could heat the room up rapidly if necessary. Incidentally, if you use a pool with a heater, the heaters tend to be most useful for maintaining temperature rather than raising it – a bucket of hot water is much quicker if you want to raise the temp quickly.

3. Stimulating the baby to breathe

This is an interesting issue, but AFAIK (as far as I know) it is entirely theoretical. Still a concern, though. It was raised in this paper:
Johnson p (1996) Birth under water -to breathe or not to breathe, British Journal of Obstetrics and Gynaecology 103(3): 202-20
where the author says that warm water is less likely to stimulate breathing.

The RCOG’s statement on birth in water (www.rcog.org.uk/mainpages.asp?PageID=641) says:

Careful control of the water temperature

The hypothesis is that warm water relaxes the muscles and encourages mental relaxation. This may then improve uterine perfusion, relaxation and contraction, thus leading to less painful contractions and shorter labours. Temperature of the water should be comfortable for the woman, although body temperature (37°C) may be the ideal. Water temperature should not rise above 37°C, however, as there is a risk of circulatory redistribution to the skin and hypotension, possibly leading to decreased placental perfusion. Also, sweating would increase, with a risk of maternal dehydration during a long immersion. Women should be encouraged to drink to prevent dehydration. For the 64 babies identified in the surveillance study, no information about temperature was given for 26 of them (41%).3

Temperature of the water needs to be carefully controlled and should be regularly measured and recorded.

No reference is given here for the assertion that 37C ‘may be the ideal’, and I wonder where it comes from, for the first stage of labour at least?

A lot of the literature on waterbirth seems to focus on theoretical concerns and isolated cases, rather than large-scale studies. While these papers may still be important and may draw attention to real issues, I think it is vital to differentiate between:
– Theoretical concerns and guidelines which are based on them, or on other guidelines
– Case studies, and
– Studies of large numbers in their various forms

I’m too tired to think through this any more, but I look forward to your thoughts!

Angela Horn
Home Birth Reference Site (www.homebirth.org.uk)

Hospital practicalities

Does anyone have any info on how hospitals who use a non plumbed pool operate a system for payment of the liners?

In our community units we mainly have plumbed pools so there is no problem there. The consultant unit has just got a self assembly pool which can be used but the couples need to buy their own liners. The proposal from the unit is that the mums need to order and buy a liner in advance from Active Birth . They do not seem to have considered what will happen if they don’t use the liner. This also means that there won’t be much spontaneous use of the pool. The unit does have 4 liners with the pool. I think with this system the pool will stay in the cupboard most of the time. The manager says it will be too difficult to administer a payment system with pay as you use!!

Juliana, NCT teacher and Mslc chair

I was interested to read Juliana’s message re paying for liners. Just wondering if the women have to pay for hotel services, pethidine, anaesthetist by the hour? – that one must be expensive! Is this a ploy to disuade women from using the pool at all. I know the NHS is strapped for cash, but perhaps we need a wider debate about spending priorities in the maternity services. In my local unit women have to pay to hire a Tens machine (although midwives do use their discretion about this, and the money goes direct to unit) but few questions are asked about the cost of other parts of the service, eg Increasing number of ultrasound scans, just one example.

Andrea

I have been involved in establishing a Waterbirth service in a Midwifery led unit using disposable liners. The unit initially purchased liners – buying ten at a time reduces the unit cost to £26. We had these available for any woman who wanted to use them. We held Waterbirth workshops for anyone who was interested in Waterbirth, and also to promote the service. During these sessions the women were advised that the liners cost us money, and asked for donations if they could afford them. This constant flow of donations ensured that anyone who wanted a waterbirth could have one. We have now bought a permanent plumbed-in pool because waterbirth has proven to be so popula,r and this might be a cheaper long term solution. It is much easier to fill and empty and overcomes a great deal of the Health and Safety, Manual Handling, and Infection Control issues.

J.W.

I’m doing a literature search on waterbirth and have got all the literature so far but have a few questions to pose to those of you who offer labour and/or birth in water (the hospital I train at doesn’t offer it at all). I’m curious about what happens outside the UK too.

1)what do you think of the issue of the chronically hypoxic fetus who attempts to breathe while s/he is being delivered underwater?

2)Do you think the benefits outweigh any risks, or after a delivery do you ‘sigh a sigh of relief’ (to quote one london midwife I spoke to) after a good delivery in water?

3) Does anyone have any protocols you are able to share with me?

So far the literature search has been a good learning experience for me – I may even be changing my mind about birth under water! I’m quickly realising that I have been trained to a great extent (in clinical areas at least) in the medical model……..

Gillian, Student Midwife

The mother of a chronically hypoxic baby should not be in the water, and I would presume that most midwives would advise that, before the head emerges, the mother should either stand up, or leave the pool. As far as protocols are concerned, I would suggest you contact those hospitals which have over 50 water births a year. Those which are only doing one or two are a waste of time because they clearly do not support water birth.

Also, suggest you get a copy of Water Birth Unplugged, proceedings of the First International Water Birth Conference, Ed. Beverley A Lawrence Beech, Books For Midwives Press, 1996.

Beverley Lawrence Beech
Hon Chair, Association for Improvements in the Maternity Services (AIMS)
www.aims.org.uk

Can the floor take the weight?

I have now decided I would like a water birth in hospital. We cannot do it at home, as we live in a first floor flat, and I am 100% certain the floor would not take the weight safely.

A few general points about birth pools and floors: I know this is a common worry, but from everything I’ve been able to find out, it sounds like it’s rarely actually a problem.

The Active Birth Centre’s literature says:

“The pool is usually filled to a depth of 22″. A square foot of water 22″ deep exerts a pressure of 95lbs upon the floor surface, which is substantially less than the average person standing in that area. .. if you are concerned, contact us for advice and if necessary consult a professional builder, surveyor or structural engineer. Since we began to design and supply our pools they have been used in a wide variety of homes and hospitals. We have not heard of any incidents where the pool caused structural damage.”

Even with the largest birth pool available for home use, the weight is no more than that of 12 or 13 people (including you) – so if you would be prepared to have 12 or 13 adults standing in your room, you’re OK with a birth pool. As the passage above explains, the weight of the pool is evenly distributed over the entire surface covered, whereas with people and some other furniture, it’s concentrated on smaller areas where, eg, feet are standing.

The weight of different birth pools varies a lot, too. The above considerations would be for a pool like the Birthworks hexagonal wooden sectional one (www.birthworks.co.uk). This tub is 5’1″ across, 26″ deep, capacity 1,000 litres (220 gallons) and weighs 1000Kg (1 tonne) filled. A metric tonne is smaller than an imperial ton (1 ton = 1.016 tonnes). Other tubs, eg their rectangular tub, weigh only half this: 4’11” long, 24″ deep, 2’11” wide, capacity 500 litres (110 gallons), weight 500Kg

I’m not aware of any incident in the UK where a floor ever has actually collapsed because of a birth pool. One birth pool hire company spokesman told me that he only really worries about 3rd floor or above in Victorian buildings, as they tend not to be very well constructed from this viewpoint.

Strongest areas of floor joists are in the corners, or in a bay window. If you’re in a first-floor flat or maisonette then you may find that there is a load-bearing wall underneath some part of your floor. This is particularly likely in a maisonette as one of your rooms is likely to be above the hall wall downstairs. If in doubt, you could ask the people downstairs to let you have a look around.

The water supply should not place any restriction on where a pool is sited as hire companies will provide extra-long hoses if requested, and tap adaptors are now available even for square bath taps (if the hire company doesn’t have them, try B&Q etc.., or else some mail-order catalogues sell extra-large square tap adaptors. I will dig out the source if anyone wants one). Being on the first floor can be a positive advantage when it comes to emptying the pool as it’s easy to siphon water out. You can hire pumps with most pools to do this if you want, but if (like me) you try to do it with the powerhead from your tropical fish tank, you may need a bit of help!

If you have gas-fired water heating (eg a combi boiler) then the pool will take 1-2 hrs to fill, though of course you can get in while it’s filling. I liked this as I could direct the hot hose onto sore bits! If you have an immersion heater only then it may take longer as you may need more than one tankful of hot water. Do a trial run first! With a combi boiler you often have a backup immersion heater too – get it turned on, just in case.

Cost varies a lot. First time around, I was nervous so I hired the full works (pool, heater, pump) for 2 weeks either side of my due date. It ended up costing around £180 I think. Second time, I hired the pool initially for 2 weeks before the date, up to the date – knowing that I’d be able to extend it if baby wasn’t here by then. Of course, all the hire companies will say they can’t guarantee that you’ll be able to keep the pool beyond the booked period, but they would say that, wouldn’t they? They want you to pay for 4 weeks up front! Most of the time you’ll be fine. I didn’t bother with heaters etc.. second time, as topping up from the hot tap seemed just as easy. So, last time, I simply hired the pool only for 2 weeks – cost £60.

A couple of things that I found useful:

• Put a large tarpaulin under the tub when you assemble it, so you have a large splash-mat all around to save your carpets when you get out. Mine cost about £8 from B&Q and has been loaned out to friends. It has been used for decorating, and has had three babies born into water above it, and one born directly onto it!
• In a birth pool, if you end up on your knees or hands and knees for a long time, your knees can get a bit sore. Putting a foam pad (or a cheap camping mat, eg £4.99 from Milletts, cut to fit) under the liner will help.

As for birth pools in hospital – lots of people plan to use them, but actual hospital waterbirths seem to be as rare as hen’s teeth. I think most of them are attended by midwives on the UK Midwifery mailing list! I’ve lost count of the number of birth stories I’ve heard where a hospital waterbirth has been planned, but for some reason of another it didn’t happen. The support of a willing midwife will probably make all the difference, though.

Angela Horn
Home Birth Reference Site

How long between birth of the head and the body?

How long can you safely stay underwater with just the head out, say if the shoulders aren’t coming after 10 or so minutes? Should you/ can you get out of the pool after the head is out or do you need to then wait for the entire body?

If the body hasn’t delivered with the next 2 contractions I would ask the woman to stand up in the pool, usually this and the extra gravity is enough to encourage the baby out! But from experience the water level is crucial as for some women standing up doesn’t mean that the baby is out of the water and they are slippery little things so 2 pairs of hands can be handy to avoid a rapid re-entry into the water by the baby. If body not out with standing then encourage the woman to lift a leg onto the side of the pool, if not born with this, get the woman out of the pool and shoulder dystocia procedure.

Only ever got as far as the standing up!

Cate

If labour has been normal and there is no shoulder dystocia, I can see no reason why there should be a long gap between the contraction birthing the head and the one birthing the shoulders. Contractions during the second stage are often wider apart than in first stage, but I wouldn’t expect the character to change during the actual birth.

If there is any sign that the baby is distressed, the mother is asked to leave the pool or stand up if the birth is imminent (Garland, 1995).

Assistance in giving birth is never undertaken under water, as tactile stimulation underwater may stimulate the baby to breathe (Garland, 1995).

Ruth

With Joshua, his head was born ok, but he had the cord wrapped around his shoulders and also had wide shoulders. I changed position in the water and that helped.

Sun

The shoulders would normally be born with the contraction following the birth of the head. Any delay and the mother should be out of the water.

Judy Bothamley and Joanne Chadwick (1996) state:

Women at high risk of shoulder dystocia are encouraged to leave the pool in the second stage before the birth…If an unexpected shoulder dytocia occurs, the mother is helped out of the pool immediately by the birth attendants. The mother’s movements, as she leaves the pool, are likely to help the baby’s shoulders to enter the pelvic cavity and expidite the birth (Gibb; Macdonald and Stirk, 1995)…The mother cannot push with her maximum power in water…’

They continue to advise regarding delivery in a squatting position or supine.

Every maternity unit should have a waterbirth policy and a shoulder dystocia policy for all types of vaginal birth.

Reference:

Bothamley.J, Chadwick,J. (1996), Evaluating immersion in water – issues to be considered regarding a randomized controlled trial. Published in: Beech.B.A. (1996), Waterbirth unplugged: Prcedings of the first International Water Birth Conference, Hale, Books for midwives Press.

Gibb,D. (1995), Shoulder dystocia: The Obstetrics, Clinical Risk, Vol 1. p49-54.

Ruth

Staying in the water after birth? Third stage in water?

My birthing history is very straight forward – both my previous children were born at home, in Bristol, both water births. .. My midwife told me of some information that she has read from a ‘leading consultant’ that letting the baby stay in the water for more than a minute when the cord has not been clamped has shown to create a greater risk of poor clotting in their blood. Do you know ANYTHING about this? ?! I didn’t have the cords clamped until well after pulsation had stopped, and the midwife with my 2nd son gently insisted that I could cuddle him in the water for ages after he was born, which was blissful.

Helen

She might be talking about a case discussed in The Lancet, which has led to guidelines about not remaining in warm pools after birth in many areas. A a mum and baby remained in the pool for quite a while (30 minutes) after birth, and basically the warm water kept the blood vessels in the umbilical cord dilated, and an excess amount of blood was transfused to the baby.

The resulting guidelines about not hanging around in a warm pool seemed sensible to me – we don’t yet understand all the mechanisms our bodies have for dealing with the third stage, but it seems quite possible that the umbilical cord needs to be exposed to the air to allow a natural regulation of blood transfusion through the cord.

On the other hand, plenty of mothers rest in pools for a while after the birth with no ill effects, so it depends on your personal assessment of the risks and benefits.

Like you, my children were both born at home into water, and I was quite happy to get out of the birth pool shortly afterwards on this account. Actually, first time round the pool was such a mess that I really didn’t want to hang around in it! Second time I thought about having a quick rest in the nice, clean water, but decided I’d rather have a comfy sofa and a cup of tea!

Angela

Severe neonatal polycythaemia after third stage of labour underwater
Lancet 1997; 350: 1445 – 1450
Topun Austin, Nicola Bridges, Michael Markiewicz, Ed Abrahamson

A 2-day old baby girl, delivered at term in a hired birthing pool at home, was referred to hospital .. because of slow feeding and floppiness. After an uneventful vaginal delivery into water maintained at around 36°C, the mother remained in the pool with her baby held at breast level whilst awaiting completion of the third stage of labour. The placenta had not delivered some 30 min later and the mother came out of the pool. After another 10 minutes, she agreed that the umbilical cord be clamped and syntocinon was given with rapid delivery of the placenta..

The umbilical cord vasoconstricts when exposed to room air and this is thought to limit transfusion to the infant. In this case it seems that the umbilical cord continued to pulsate whilst it remained in water at body temperature and more blood than usual was transferred to the infant.

We suggest that if a third stage without assistance is planned during a water birth the mother and baby should vacate the pool, or if they remain, the cord be clamped within a minute or so.

You can read the letter on The Lancet’s website but will need to register (free) at www.thelancet.com first. Then you can go to the article directly at:www.thelancet.com/newlancet/reg/issues/vol350no9089/research1445_1.html