From MIDWIFERY MATTERS, Issue No.122
by Amanda Benko - newly qualified midwife
The very first birth I witnessed as a student midwife was a woman having a physiological waterbirth. I found the experience amazing and deeply moving. It convinced me that immersion in water works wonders as an analgesic, muscle relaxant, stress alleviator, hypotensive agent and diuretic. There was minimal perineal trauma and the couple had the most positive physiological birth experience they could wish for. This experience made me understand why midwifery training concentrates on normal birth; why it is important to believe in the abilities of women's bodies. For me it highlighted the importance of midwives supporting women and giving them confidence in the normal physical function of labour and birth. As my midwifery training went on, I was pleased to see many midwives promoting the benefits of waterbirth and giving women the choice. Waterbirth seemed a natural topic for my dissertation. When looking at the wider picture, I found evidence that waterbirth could be offered as a possible option in some 'at risk' pregnancies. Below is an excerpt from my recent dissertation as part of my midwifery degree.
Miller (2006) suggests that if midwives wish to enhance their job satisfaction, make birth more satisfying for mothers and babies, and are committed to restoring normality in birth, then every woman without major complications should be offered the opportunity to labour and give birth in water. In order to make an informed choice about whether to use a water pool during labour and birth, women need appropriate information and support in considering the advantages and disadvantages (MIDIRS, 2008). When discussing options for pain relief antenatally, midwives should include using immersion in water. It is important that midwives have up-to-date knowledge and information on the latest research and evidence relating to the advantages and disadvantages of labour/birth in water (RCOG/RCM 2006).
Burns (2004) believes that waterbirth is associated with higher maternal satisfaction than birth on dry land. In a questionnaire assessing women's views on waterbirth, Richmond (2003) found that when women got into the pool in labour many of them described feelings of complete relaxation. Women felt they were given immediate pain relief and the warmth was soothing. Many mothers enjoyed the buoyancy and mobility the water gave them. Miller (2006) believes that women using a water pool feel more empowered and less exposed. Immersion in water increases self control in a secure, warm, private and quiet environment, thus encouraging the production of endorphins, nature's own pain relief. Endorphins produce a sense of well being which helps us tolerate physical pain and they also have an amnesiac effect, preventing us from remembering much of the pain (Garland 2004).
In a study comparing waterbirths and conventional vaginal deliveries, Otigbah et al (2000) report that labouring and delivering in water is associated with a shorter labour and reduced perineal trauma for primigravidae women. All women require less analgesia. Odent (2000) suggests that if a small number of recommendations are taken into account, using water during labour will seriously compete with epidural anaesthesia. In a recent study Gessbuhler et al (2004) found that perineal trauma is minimised during a waterbirth: episiotomy is hardly ever needed; there are fewer first and second degree perineal lacerations, and fewer vaginal and labial tears. Hale (2008) believes this is owed to the softening effect of the warm water and the woman' s ability to relax her perineum more readily. Support from the water slows the crowning of the baby' s head and offers perineal support which decreases the risk of tearing (Garland 2004). Women with prolonged labour found a reduction in obstetric intervention following immersion in water and instrumental delivery is also rarely necessary (Cluett et al 2004). Beech (1998) points out that labouring in a birth pool encourages an upright position and increases the pelvic diameter which often increases the rate of cervical dilatation. Waterbirth reduces the need for pain relieving drugs; however, if it does not work the woman has the option of choosing other forms of pain relief.
Most research on waterbirth focuses on low-risk pregnancies. Very little research has been done on waterbirth in high risk pregnancies and therefore hospital policies and guidelines are often based on opinion rather than research. Opposition to a waterbirth for women with high risk factors is not based on evidence but rather on lack of training, knowledge or experience. Some pregnancies are considered high risk because of pre-existing conditions such as diabetes, infection, group B strep, obesity or previous caesarean section; others, such as pre-eclampsia or multiple pregnancy, may relate to the current pregnancy. Lindsey (2006) points out that women considered high risk have the same needs and expectations of midwifery care as any other woman. Midwives need to support these women to help them achieve a successful outcome. Good clinical skills are not enough, midwives should consider the woman holistically. The best care involves maintaining as much normality as possible. Lindsey (2006) states, “This is not a fixed care package; one size does not fit all and creating normality will be as individual as women are’. Many women classed as high risk miss out on options they would have been given had all been ' normal'. Offering them the chance to labour in water encourages a return to normality and thus will have an enormous impact on the woman' s self esteem, her confidence, her knowledge and her mothering abilities. It may also have a long term impact on the child.
Lindsey believes that the experience of high risk pregnancy can be very disempowering both for women and for midwives. The woman enters a medically defined environment where choices and decisions are not hers alone; she feels she has to hand over the responsibility of her care to the ' experts' . What can midwives do to enable high risk women to choose waterbirth? Midwives who want such women to be thus empowered must work collaboratively with managers, obstetricians and pediatricians in order to provide safe and effective care for all women and babies. If there is resistance from midwives in supporting waterbirth for low risk women, how much more of a challenge it is to offer it to high risk women.
Midwives should be involved in developing guidelines and working with other healthcare professionals to standardise these guidelines. Consideration should be given to health and safety issues, infection control and determining evidence based practice (Winters & Duckett, 2006). It is important to develop networks and pathways for clinical care, recognising clinical leadership, multidisciplinary working and each others' responsibilities within teams (DoH, 2007). By educating, sharing knowledge and evidence, being supportive and by following agreed guidelines and policies, healthcare professionals will be able to work together in the best interest of women and babies, enabling them to achieve the positive and satisfying birth experience expected by today's parents (DoH, 2007).
Heavier women, women with spinal problems or those who have a disability which limits mobility may benefit from the supportive qualities of water during labour (Balaskas, 2004). Immersion in water offers labouring women enhanced buoyancy and mobility with much less effort (Campbell 2004).
The incidence of obesity is increasing in the UK population and in the most recent confidential enquiry into maternal deaths, 35% of women who died from either direct or indirect causes had a BMI of more than 30. Complications can be related to an increased BMI and also in terms of diseases related to obesity. Obesity increases both the need for obstetric intervention and makes intervention more complicated (Irvine & Shaw, 2007). For a woman with a raised BMI, immersion in water for labour and birth enables her to move and change positions easier and quicker than if she was in a semi-reclining position on a bed. This mobility can utilise the advantage of gravity, enlarge the pelvic outlet and enhance fetal descent urging a better pushing technique in the second stage (Simkin & Ancheta, 2005). Studies have found that immersion in water during labour reduces intervention by health professionals (Cluett et al, 2002 and Geissbuehler et al, 2004); wouldn' t it be beneficial to give these women the option of using a water pool? In water there is no weight or compression on the mother' s lower back, making it easier for the baby to negotiate the pelvis and more comfortable for the mother. There is no compression of the internal blood vessels from the weight of the heavy uterus and abdomen, this helps to ensure that the baby has enough oxygen throughout labour and reduces the risk of fetal distress (Balaskas 2004).
Attitudes about the use of a birth pool by mothers who have had a previous caesarean section can vary greatly. Although there is some increase in risk after a previous caesarean section, this is mainly the risk of scar rupture. However, provided that labour progresses well and is properly monitored, the chances of a problem occurring are very slim (Balaskas, 2004). Chadwick (2009) requested a VBAC waterbirth with her third baby and met with some resistance. The main objection was the alleged need for continuous monitoring, which the registrar said would not be possible in the pool. However, a monitor that can be worn continuously in the pool is available. Chadwick looked at the evidence for continuous monitoring and concluded that it was not the only – or indeed most reliable way – of detecting uterine rupture. After support from a well respected midwife who had built up mutual trust with her consultant, Chadwick was pleased to have the satisfying and positive waterbirth she wanted.
Beech (1998) thinks it a pity that some practitioners still use the threat of potential complications as a means of denying mothers waterbirth. She believes it is a way of undermining the confidence of midwives. Sellar (2008) welcomes the recent positive change in attitude to some women' s need for normal labour after caesarean section. By building up mutual trust with management and consultants, midwives are able to empower some women to have the positive birth experience they want. The RCOG statement on waterbirth (2006) observed that women with previous caesarean section have used water for labour and birth without reported problems, however, in many maternity units there is still a great deal of resistance from both management and the medical establishment, despite the fact that there are midwives who support this practice. Given the ever rising caesarean section rate and the call for promotion of normality, there may well be plenty of demand to offer women a VBAC waterbirth in the future (Sellar, 2008).
Midwives need to remember the importance of women feeling in control of their labour and birth experience by providing a more social model of care and by demedicalising their care. In order to make an informed choice about whether to use immersion in water during labour and or birth, women need appropriate information and support in considering the advantages and perceived risks associated with water pool use. Ideally women should be given information on water immersion during the antenatal period and the guidelines for use of the pool discussed before labour. Richmond (2003) believes better antenatal preparation of women for waterbirth is needed to reduce the need for other forms of pain relief. Maternity Matters (DoH, 2007) highlights the importance of providing a more flexible antenatal service designed around the needs and choices of women and their partners. This report also asserts that all women should have access to their midwife in their local community in order to discuss their choice of where and how they wish to give birth. Women have many adjustments to make in pregnancy, both physical and psychological. Lindsey (2006) believes that continuity of care is immensely valuable, allowing the midwife to give good psychosocial support and support normality as far as possible for each individual client. Midwives should promote waterbirth as an aid to normal birth rather than seeing it as a fashion or unusual choice. They should discuss the benefits at every opportunity. Promoting and offering waterbirth to women at higher risk of complications will foster a profound belief in the normality of birth for most women (Winters & Duckett, 2006).
The RCOG/RCM statement on immersion in water for labour and birth highlights a need for more research around waterbirth, however, the evidence currently available does not justify discouraging women from choosing waterbirth (Hale, 2008). The latest research suggests that labouring in water is of benefit to women. Women cope better with the pain of labour in water and so have a reduced need for pharmacological pain relief. Women' s labour progresses better in water and so there is a reduction of ' failure to progress' and the need for augmentation of labour. The research reviewed suggests that neonatal outcome is no different for those born out of water than those born in water (Rafferty, 2008). The midwifery profession is expected to undertake evidence based practice (NMC, 2008) and therefore midwives need to make use of well designed research. In the meantime, audit data is promising (Burns 2004). Garland (2006) believes that an audit-based rather than a research-based approach is appropriate when evaluating the evidence regarding waterbirths; this underpins a more reflective stance and supports the overall ethos of woman-centred care. However, given the current evidence, midwives should feel comfortable and confident in offering and supporting mothers to choose immersion in water for labour and birth (Burns, 2004).
As the word is spread throughout both the healthcare profession and local communities, more women from all groups will be able to experience the benefits and tranquility of waterbirth without fear of discouragement.
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This article was originally published in Midwifery Matters issue 122, Autumn 2009
AH updated 22 October 2009