Considerations

Many women will choose to bath or shower in labour, the benefits of warm water bringing comfort and relief to the discomfort of uterine contractions. Immersion in deeper warm water is increasingly used for these benefits, but also for the birth of the baby into similar surroundings. Providers of maternity care should be familiar with the evidence of its efficacy and safety and have protocols that assist women and midwives if this choice is utilized. Water used in this way may be in a home or hospital setting, using pools that may be permanent or hired.

Considered benefits and safety of water use

During the first stage of labour, water can (adapted from Garland 2011):

As maternity care providers, midwives can experience increased job satisfaction and the service attracts staff and clients (Garland 2011). Garland (2011) also notes that there can be some less positive aspects: costs can prevent some clients from hiring pools, this also often makes it a ‘white middle class’/elite activity; midwives need training and support; midwives need additional guidance in the care of their backs. The occasional poorer outcome can cause the media to create a storm.

Both NICE (2014) and the RCOG/RCM joint statement (2006), in the light of currently available evidence, endorse labouring in water for pain relief purposes in the first stage of labour where inclusion/exclusion criteria exist. The RCOG/RCM (2006) are prepared to state, too, that ‘healthy women with uncomplicated pregnancies at term… should be able to proceed to water birth if they wish’. NICE (2014) are less sure, stating that ‘there is insufficient high-quality evidence to either support or discourage giving birth in water’. Garland (2011) indicates that many of the studies are robust and show positive outcomes, but are often small studies. However, Burns et al (2012) included over 8000 women in their review over an 8-year period: 58.3% were water births, just over half being to primiparous women. They concluded that pool use was associated with a higher frequency of spontaneous and normal birth, particularly among primiparous women.

Physiological differences

The physiological differences contribute to the safety. Babies experience an increase in prostaglandin in the 48 hours before labour commences and from 4 cm of cervical dilatation so that fetal breathing in utero ceases and the baby is not able to gasp or inhale during the birth process (Harper 2014). Equally the physiologically mild hypoxia that all babies have at the end of labour encourages them to swallow, none of us is able to swallow and breathe at the same time – breathing is inhibited until the first swallow has taken place. Along with these actions, the dive reflex (present until 6–9 months of age) closes off the glottis to abnormal substances so that fluids cannot be inhaled into the lungs.

The severely compromised fetus, however, will gasp; on this basis, signs of fetal compromise should exclude the woman from the water, either earlier in labour or if necessary standing out of the water at the point of delivery. The baby’s face should never be reimmersed once out from the water.

Babies born into warm water are less likely to cry, they have a continued supply of oxygen through their umbilical cord and are likely to take longer to become pink all over. For this reason Apgar scoring should take place at a true 1 minute; Apgar scores taken before then are unlikely to be correct and could suggest fetal compromise when this is not the case (Garland 2011). It should be that all Apgar scores at all deliveries are assessed at 1 minute, but Garland (2011) noted that if estimating when 1 minute has passed, midwives are capable of under- and overestimating the time.

For the mother it is noted that with less gravity there is often a passive second stage. This means that sometimes the fetal head is on the perineum without signs of pushing, but it also means that there is often no faecal contamination of the water. This is an important aspect of safety.

Who is suitable to use a birthing pool?

In many situations the inclusion criteria is the same as that for birthing in a midwife-led unit or at home: low-risk women suitable for intermittent auscultation in labour. However, any woman who has been given all the available information and wishes to use the pool should be considered. If the woman makes a choice that the midwife is uncomfortable with, Supervisors of Midwives can support the woman and the midwife, this and other actions that can be taken are discussed in Chapter 35.

General inclusion criteria for pool use:

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