GUIDELINE TITLE: Water in Labour and for Birth the Use Of

/ Women’s Multidisciplinary Guidelines
Page 2 of 16
Maternity Services / Date of issue: 21/01/09

GUIDELINE TITLE: Water in labour and for birth – the use of

UNIQUE IDENTIFIER / (Generated by SharePoint)
VERSION No / 2
LEAD AUTHOR’S NAME / Lead midwife for normality – Labour Ward
LEAD AUTHOR’S ROLE & DEPARTMENT / Labour ward coordinator
APPROVAL BODY 1 / AMMG Guidelines Group
COGS
Labour Ward Forum
DATE APPROVED: APPROVAL BODY 1
APPROVAL BODY 2 / Trust Guidelines Group
DATE APPROVED: APPROVAL BODY 2
REVIEW DATE / September 2013
LEAD PERSON FOR REVIEW
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DOCUMENT REVIEW HISTORY

REVIEW DATE / REVIEWED BY
23.10.08
21.01.09
10.08.11

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CONTENTS PAGE

Page No
1.  Introduction
2.  Management
3.  Glossary of terms
4.  References
5.  Appendices

1. Introduction
The use of water in labour and for birth has been available in the United Kingdom since the 1980s becoming widespread after the Winterton Report1 recommended that all maternity units provide women with the option to labour and give birth in water. The Cochrane Review 2004 conclude that there is evidence that water immersion during the first stage of labour reduces the use of analgesia and reported maternal pain, without adverse outcomes on labour duration, operative delivery or neonatal outcomes. The effects of immersion in water in the third stage of labour are unclear. One trial in this systematic review explores birthing water, but the authors conclude that it is too small to determine the outcomes for women and neonates (Ibid 2004). The principle reason for using a birthing pool is not to have the baby born underwater but to facilitate the birth process and reduce the need for intervention and drugs. Qualitative research reveals women felt that using water had supported their feeling in control, relaxation, relief and warmth and relief of pain on entering the pool. Women who had previously experienced birth, waterbirth compared favourably as they felt more in control, more relaxed and found labour less painful.

Statement of intent

Airedale NHS Foundation Trust fully recognises that the obligation to implement guidance should not override any individual clinician to practice in a particular way if that variation can be fully justified in accordance with Bolam Principles. Such variation in clinical practice might be both reasonable and justified at an individual patient level in line with best professional judgement. In this context, clinical guidelines do not have the force of law. However, the Trust will expect clear documentation of the reasons for such a decision and for this variation. In addition, any decision by an individual patient to refuse treatment in line with best practice must be respected, escalated to the consultant and fully documented in the appropriate records of care/treatment.

“A midwife has a statutory duty to attend a woman in labour, regardless of whether that is in hospital or in the community, and is governed by the NMC and the LSA. If a woman chooses to deviate from this guideline, the midwife should seek further guidance from a Supervisor of Midwives whilst continuing to give the best possible care”.

Acknowledgement and thanks must be given to the Consultant Midwife / Head of Midwifery, Helen Shallow, C&HNHSFT for permission to adapt their guideline which has been in use since 2005.

Aim

(i)  The aim of this guideline is to provide clear guidance to Midwives when facilitating labour in water and birth underwater. It will also present the evidence around the use of water for relief of pain in labour and for birth, so enabling women to make informed decisions about pain relief.

(ii)  Scope and locations where this guideline applies
This guideline applies to hospital and community midwives caring for women having homebirths and births within the labour ward at Airedale General Hospital.

(iii)  Patient and carer information
In the event of a woman using a water birth pool at home, it is the responsibility of the woman or her partner, to hire, assemble, maintain, fill and empty the pool. The mother needs to be informed that in the event of an emergency she will be asked to leave the water.

2. Management
Midwives must be mindful of the principles of manual handling when assessing mothers from the pool. Mothers must be informed of the Trust manual handling policy.

Criteria for use

·  The midwife should discuss the option of the pool for labour and birth ensuring the woman is fully informed.

·  The midwife should be conversant with the most recent literature findings and feel confident to undertake water birth.

The women should be low risk and midwifery led:

(Ref. – Intrapartum Risk Assessment – See Appendix 2)

·  37 weeks and over

·  Cephalic presentation

·  Singleton pregnancy

·  No history of shoulder dystocia

·  Body mass index below 35

·  Be ambulatory enough to get in and out unassisted, of an empty pool in early labour

·  Normal fetal heart rate

·  No obstetric or maternal complications

·  Clear liquor when membranes ruptured

·  Opiates should not have been administered within the previous 2 hours

·  Ruptured membranes <24 hours

·  No significant fetal abnormalities

·  If using entonox in the pool a woman must be able to support herself unassisted

·  No infective skin conditions, e.g. impetigo

·  Have normal vital signs on admission in labour

The following should also be taken into account

Before entering the pool the midwife should inform the woman that she will be advised to leave the pool if:

·  Meconium stained liquor occurs

·  Maternal pyrexia above 37.5

·  Any signs of antepartum bleeding

·  Failure to progress (as per guidelines)

·  Abnormal fetal heart rate / pattern

The above list is not exhaustive.

Where a woman does not fulfil the eligibility criteria for a waterbirth but continues to request one, a referral must be made to the Senior Midwife / Supervisor of Midwives / Obstetrician

Contraindications for water pool use

·  Any pre-existing reasons to be concerned about mother or baby (see Intrapartum Risk Assessment – See Appendix 2)

·  Women who are afraid of water

Use of the pool

·  The pool should be prepared so that the water depth facilitates mobility whilst also allowing the mother to expire heat

·  Water temperature during the first stage of labour should be tested and recorded hourly and should be kept comfortable for the woman and not above 37.50C

·  It is preferable that labour should be established (cervical dilation at 4cms+) prior to the woman entering the pool and in the latent phase of labour mobilisation should be encouraged.

·  The time of entry to the pool must be recorded on the partogram.

·  If narcotic analgesia has been given prior to established labour an assessment of the woman should be undertaken to ensure she is not drowsy before entering the pool. A minimum of 2 hours should have elapsed.

·  The observations and care of mother and baby should follow usual practice in accordance with Airedale NHS Trust guidelines for normal labour, with the addition of maternal temperature being recorded hourly. The fetal heart should be ausculated using a waterproof sonicaid to facilitate maternal comfort.

·  It may be preferable to perform vaginal examination outside the pool.

·  If there is meconium present when the membranes rupture and birth is not imminent, ask the woman to leave the pool.

·  The pool room should be at a comfortable, ambient temperature and it may be necessary to regulate the room temperature with the use of a fan or opening windows. NB the cooler room temperature at time of birth contributes to the onset of neonatal respiration.

·  The woman should be encouraged to drink regularly to prevent dehydration in the warm environment.

·  For the birth there should be minimum interference from the birth attendant.

·  The presenting part should be allowed to deliver spontaneously. The water temp should be as near to 37c as possible.

·  If the baby does not deliver with the next contraction, the midwife should feel for the cord. If the cord is tight around the neck the mother must be assisted from the pool. Under no circumstances should the cord be clamped and cut underwater.

·  When the baby is born it should be assisted to the surface. The mother can then hold the baby in skin to skin contact whilst the baby is observed for breathing movements.

·  The cord must be checked to ensure it is intact. If the cord has snapped, the severed ends must be clamped immediately to prevent leakage.

·  Whilst the mother remains in the pool the baby’s trunk should remain under water to avoid hypothermia.

·  Women should be advised to consider leaving the pool for the third stage of labour (RCOG 2006) when women birth in water however, their upright position often facilitates a speedy physiological birth of the placenta (Scott 2001). It is therefore important that the Midwife is competent in both physiological and active management of the third stage. With physiological third stage the cord remains intact until the placenta is expelled by the mother, who may have been asked, or spontaneously puts the baby to the breast; which stimulates oxytocin secretion. Occasionally when the placenta is slow to separate, the woman may tire of waiting and requests to move on to active management. Active management should never commence whilst the woman is in the pool. Help her to exit the pool and then proceed.
NB if the woman’s physical condition raises concern, if a tachycardia is evident or if the blood loss appears excessive the woman should be asked to leave the pool and active management commenced.

·  The mother and baby should be dried and kept warm after leaving the pool.

·  The perineum should be assessed for trauma. If suturing is required it may be necessary to delay this for up to an hour to allow perineal tissue oedema to subside.

·  Blood loss should be estimated as less than or more than 500mls. Clots should be collected using a sieve.

·  The pool should be disinfected and cleaned thoroughly using the current methods advocated by the Trust’s infection control department. See http://sharepoint-srv2/C10/Clinical%20Guidelines/Compiling%20a%20Guideline/Decontamination%20cleaning%20and%20disinfection%20Guideline.doc

·  Complete audit form pertaining to water labour / birth.

Obstetric emergencies in the pool

The probability of a woman collapsing and being unable to get herself out of the pool is very low due to the strict criteria applied to the selection of women suitable for the birthing pool.

The first aim should be to anticipate and detect early an obstetric emergency event. If the midwife has any concerns that this is a possibility then she/he should ask the woman to leave the pool. Most women when faced with an emergency situation are very agile and are able to get out of the pool with minimal assistance. However if this is not possible, most emergency situations can be managed with the woman still in the pool. In the event that the woman is unable to leave the pool unassisted (i.e. she has lost consciousness) then help will be required. See point 5 below.

Possible obstetric emergencies include:

1.  Cord tightly around the neck
If the cord is tightly around the neck, the woman should be helped to stand and the pool drained. This is now not a waterbirth. If the woman is unable to get out of the pool she should adopt a supported high squat with the head clear of the water before clamping and cutting the cord. Deliver baby then sit her down again.

2.  Shoulder dystocia
PULL EMERGENCY CALL BELL. (999 IF AT HOMEBIRTH)

Try to deliver out of the pool or in a supported squat as suggested in point 1 above. This will be sufficient in most cases. Otherwise attempt to deliver on “all fours”. See also Shoulder dystocia guideline.

3. Baby requiring resusitation

·  Clamp and cut the cord immediately and remove from the water

·  Commence resuscitation procedure and PULL EMERGENCY CALL BELL.

·  Call paediatric Crash Team by ringing 2222. NOTE IF AT HOMEBIRTH, PARTNER TO CALL 999 AMBULANCE IMMEDIATELY.

4. Post partum haemorrhage

·  While the woman is able, assist her out of the bath onto a bed

·  PULL EMERGENCY CALL BELL. CALL 999 AMBULANCE IF AT HOMEBIRTH

·  Give Syntometrine 1 ml

·  Empty the bath if woman can not get out

·  Active management of 3rd stage

·  Rub up a contraction

·  Insert iv cannula. Dry the woman and keep her warm.

·  If not already done, transfer woman to bed; continue management of post partum haemorrhage according to protocol

5. Maternal collapse

·  Do not drain the pool; the buoyancy offered by the water will assist staff.

·  The midwife in attendance will PULL THE EMERGENCY CALL BELL and the assisting midwife call 2222. IF AT HOME, BIRTHING PARTNER TO CALL 999 FOR AN AMBULANCE.

·  The midwife in charge will take responsibility for maintaining the woman's airway and directing the handlers. Sitting on a stool behind the woman, she/he should support the woman's upper body and ensure her face is held clear of the water. Management of the woman’s airway will be handed over to the anaesthetist on arrival, or paramedic if in community.

·  It will be necessary to manually handle the woman out of the pool using as many handlers as are present, being as careful as possible to protect everyone's health and safety.

·  The bed will be positioned next to the pool for this transfer. This drill is to be practiced as part of the water birth workshops.

Audit of outcomes

An ongoing audit of outcomes of both labouring and birthing in water must be undertaken for every mother using the birthing pool using the audit tool in Appendix 1. The results of this audit must be reviewed on an annual basis by the Labour Ward Forum.