Chapter 5. Using water in labour
Introduction
The use of water in labour has become more acceptable in recent years. In Europe, the use of water was advocated as a source of relaxation (Odent 1984), in response to the pioneering work of Igor Tjarkovsky in Russia (Mackey 2001). However, it is believed that in other countries, water has been a source of comfort for labouring women throughout history (Garland 2006a). There are links with the use of water in labour and the spiritual nature of birth (Garland 2000, Wickham 2001). The increased desire of women to choose to labour in water worldwide has subsequently led to an increase of birth in water, websites relating to the subject and companies providing pools, both to women direct at home and to birthing units.
There is evidence to show that the use of water in the first stage of labour has benefits, including higher feelings of control by women (Hall & Holloway 1998) experiencing less pain (Cluett et al 2002, Eberhard et al 2005), less use of augmentation by syntocinon and less need for epidurals (Cluett et al 2004, Eberhard et al 2005). The aim of this chapter is to consider the issues surrounding the use of water in labour and birth, both at home and in an institutional setting, and the role of the midwife in these situations. This chapter should be read alongside Chapter 4 relating to ‘Non-pharmacological methods of coping with labour’.
Antenatal preparation
As the use of a warm pool or bath in labour is becoming increasingly common, midwives should be active in discussing this option with women in the antenatal period. The midwife needs to be aware of local policies relating to labour and birth in water and able to give the appropriate information to women about the resources available. The woman should be encouraged to consider the advantages and disadvantages of using water for both labour and birth. Explanation regarding policy about the birth of the third stage should also be given. If a woman is wishing for a home water birth the midwife should ensure she is confident in the care of women in the situation. If she is not confident she should approach her supervisor of midwives to put a plan of action in place to develop her skills and knowledge in this area. She may be able to access local study days or in-service education and spend time working with another midwife who is already proficient in the use of water for labour and birth.
The midwife will also need to be aware of sources where women may purchase or rent pools for home use, as well as what is available in the local maternity units. Knowledge of the accessibility and availability of pools should lead to the appropriate choice for the individual woman of the place of birth. Midwives can also help women prepare the home for the birth and ensure there is sufficient room for the pool, safety in the home and provision of equipment. A ‘practice run’ for the birth should take place to ensure the equipment is working effectively and that it is situated in an appropriate place. In some situations it may be necessary to obtain a structural survey for a property should a pool be situated upstairs as water is very heavy. Assessment of the length of time to fill the pool should be made as well as consideration of how a woman will get out of the pool in an emergency.
Find out which local units have birth pools. How often are they in use?
How frequently are women turned away from using it due to it being in use?
Access the Home birth website and find out about the different pools available to women at home: http://www.homebirth.org.uk/water.htm
Labour in water
The use of a warm water bath during labour is a valuable way to relieve pain (Cluett et al 2002, Eberhard et al 2005). The NICE intrapartum care guideline advocates that women should have the opportunity to use water for pain relief during labour (NICE 2007:19). The use of a bath or shower may also be of benefit, particularly during early labour. However, the depth of the pool to the level of a woman’s breast is thought to be more appropriate and women appear to welcome a large enough pool to enable the ability to move around (Maude & Foureur 2007).
It is stated that any woman who has an uncomplicated pregnancy and is experiencing a straightforward labour should be recommended to use water in labour (RCOG/RCM 2006, NICE 2007). However there are suggestions that women who have hypertension may also benefit from the relaxing properties of water in pregnancy (Katz 2003), though this is yet to be investigated in labour. There are also reports of twins and babies presenting by the breech being born in water (Evans 1997). Appropriately assessed women who have had a previous caesarean section have successfully used water in labour (Garland 2006b), however local midwifery guidelines often limit the use of a birthing pool to women with an uncomplicated obstetric history. Further research regarding the use of water in labour is urgently needed to enable women with a range of obstetric backgrounds, to use a pool with confidence.
Practical issues
According to NICE (2007) there is insufficient evidence to suggest when the best time is for a woman to get into a birth pool. Michel Odent (1997) suggests there is benefit for women to wait to enter the pool until labour has become established. It is suggested that the anticipation of getting in the water, including listening to the water fill and seeing it, may help women lose their inhibitions and also be significant in the process of the labour (Odent 1997, Maude & Foureur 2007).
In the hospital situation the midwife will need to prepare the pool for use. She will need to establish if it is clean, if all equipment is ready and will need to fill the pool. Box 5.1 explains the equipment that should be available for a pool birth.
Box 5.1
Equipment required
• A deep pool
Rationale So that the woman may immerse and move around
• Step, or access to pool
Rationale For woman to get in and out easily; for midwife to access if required
• Equipment to fill and empty it with hot and cold water
Rationale To maintain a comfortable temperature for the woman
• Thermometer for pool
Rationale To check temperature of water hourly
• Thermometer for mum
Rationale To ensure she is not hypo-or hyperthermic
• Plenty of towels
Rationale For when the woman wishes to get out of the water
• Waterproof floor and furniture protector if in the home
Rationale To protect the floor and furniture from splashes
• Mirror (some midwives use a tile)
Rationale To visualize the emerging baby on the bottom of the pool
• Torch and spare batteries
Rationale To visualize the baby in dim lighting
• Sieve
Rationale For removing debris from the pool
• Something for the midwife to kneel or sit on
Rationale For the comfort of the midwife
• A waterproof doppler or pinard
Rationale To monitor the fetal heart rate
• Long gloves if required
Rationale To protect the midwife’s arms
• Complete change of clothes for midwife
Rationale In case the midwife gets wet
• Something for the woman to lie down on (mattress, sofa, bed)
Rationale In case she wishes to get out of the water and rest and for after the birth
• A birth stool (hospital)
Rationale For the woman to sit on for the third stage
• A bucket or dish
Rationale To ‘catch’ the placenta and membranes in
• Resuscitation equipment
Rationale To resuscitate the baby if required in emergency
Tricia Anderson (2004) examined the evidence around the optimum temperature of the water and maintained that women in labour in a birth pool should be able to decide for themselves if it is too hot or cold (also see Geissbuehler et al 2002). However, anxieties over potential risks of hyperthermia to mother and baby led NICE (2007:19) to advise that the temperature of the water should be maintained below 37.5°C. This means that monitoring should take place of the water temperature. The woman’s partner can help by adding hot or cold water as the woman requires.
First stage of labour care
Monitoring should also take place of the woman’s temperature on an hourly basis (NICE 2007:19) and monitoring of the fetal heart in accordance with the usual labour guidelines (NICE 2007). A midwife should consider how she is going to carry this out. She may need to consider whether she needs something to stand on to reach into the water, if the woman will be expected to stand up and whether there is electronic equipment suitable for underwater use. She will also need to think about what clothing she will need to wear for the labour as she could become wet. An extra set of clothes is advisable, and she may require elbow length gloves. Vaginal examinations, if required, may be carried out in the water, or the woman may prefer to get out for this. Record keeping should be exemplary in accordance with the rules of practice (NMC 2004).
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