Water can provide a calming environment for women. Once in active labour, water can enhance uterine activity, provide effective pain relief; thereby reducing the need for an epidural and unnecessary intervention (Cluett et al, 2018) and the length of the first stage may be reduced.
Use of Water for Labour and Birth (503)
Warning
What's new / Latest updates
08/05/2024 Addition of STANDARD OPERATING PROCEDURE - Care of Women choosing Water Immersion for Labour and Birth as an appendix to this guideline.
Objectives
Both the Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives support labouring in water for healthy women with uncomplicated pregnancies (RCM, RCOG, 2006).
The aim of this guideline to provide the best available evidence to assist midwives in facilitating the safe and effective use of water during labour and birth.
Audience
The following guideline is for use in hospital, community midwifery unit and homebirth settings.
Please report any inaccuracies or issues with this guideline using our online form
Rationale for guideline:
It facilitates evidence based, respectful midwifery care which in turn promotes viewing the birthing experience through a positive lens (Lewis et al, 2018).
Results in fewer epidurals and no evidence that labouring in water increases adverse outcomes for women or neonates (Cluett et al, 2018).
An option in all birthing settings in GGC alongside traditional birthing techniques. Therefore, midwives need to be competent and confident in the use of the birthing pool for labour and birth (RCM, 2018).
Water birth can be beneficial to women with uncomplicated pregnancies, therefore may be a useful tool in reducing intervention rates (Maude, 2020).
There is a common belief that early entry may reduce the length, strength, and frequency of contractions (Cluett et al, 2018). It is believed that the most appropriate time to enter the water is when labour is established and contractions are increasing in length, strength, and frequency.
Women should not enter the water within two hours of a single opioid administration or if they remain drowsy. If the woman has had multiple doses, they should be advised to wait for four hours (NICE 2017).
Evidence suggests water temperature should be regulated by the woman’s comfort (Alfirevic and Gould 2006). Some research indicates that, during the first stage of labour, the water should be between 36-37⁰C. Although, it is widely recommended that the temperature should be between 37-37.5⁰C for second stage and should not exceed 37.5⁰C at any point (NICE 2017).
The water temperature should be recorded hourly and following any top up of water. The ambient room temperature should be comfortable for the woman.
Maternal temperature should be recorded hourly as per intrapartum pathways. If the temperature rises above 1⁰C from the baseline temperature the water must be cooled down or the woman must be asked to leave the pool until her temperature returns to normal.
A maternal temperature of 37.8 or higher should prompt exiting the pool and managed as per the maternal sepsis guideline.
The fetal heart should be monitored using waterproof Doppler and in accordance with the guidelines for fetal monitoring. The guidelines for continuous wireless waterproof electronic fetal monitoring should be used for high risk women, including hourly peer CTG reviews.
The woman should be encouraged to leave the pool to empty her bladder at regular intervals.
Frequent drinks should be encouraged to prevent dehydration.
Vaginal Examination should be performed out of the water.
A “Hands off” approach at delivery is recommended. Do not feel for cord – the baby will be born spontaneously.
The baby should be slowly and gently guided to the surface, face first.
Undue traction on the cord should be avoided.
If the woman raises herself out of the water following delivery of the baby’s head she must not re – immerse herself.
If there is lack of descent/advancement of the head the woman should be asked to stand out of water.
If there are any concerns with restitution and delivery of the shoulders the woman should stand, clear of the water and- be transferred out of the pool.
Following birth, assess baby as per neonatal resuscitation guidelines and initiate as required.
Please refer to Appendix 1 for criteria for exiting pool.
Women who have experienced an uncomplicated labour and birth should be able to choose a physiological 3rd stage. This may take place in or out of the pool.
If an active 3rd stage is required, no oxytocic drugs should be given in the pool.
Examination of the perineum should be performed on exiting the pool and allow one hour before commencing perineal repair if required, unless there is excessive bleeding. A prontosan soak can be applied to the perineum during this time.
All midwives should be aware of infection control implications when facilitating a water birth.
If the pool is not used for 24 hours, water should be flushed through the system for 2 minutes.
Visible solids should be removed and if the midwife feels there is heavy contamination the woman should be advised to leave the pool.
Before the woman returns to the water, the pool must be emptied, cleaned in accordance with current infection control recommendations and thoroughly dried before refilling.
Women with blood borne infection must have an individualised care plan by the MDT in place. Although the quantity of water will seriously reduce the risk from blood borne viruses, universal precautions should always be taken. Midwives should pay attention to transmission via sclera and should wear protective glasses for birth.
Prior to entering the pool, it is important that all women are risk assessed including a manual handling assessment.
Any unnecessary manual handling whilst the woman is in the pool should be avoided. The woman should be encouraged to position the fetal Doppler herself, or to raise her abdomen out of the water for the midwife to position it.
The area around the pool should be kept dry; any spills should be wiped up immediately to prevent any slips.
Women who develop complication(s) during their labour or birth should be advised to exit pool while they are able to do so.
The midwife should not attempt to remove the woman from the pool if she is unable to move. In this instance the midwife should:
- Call for immediate assistance.
- Maintain the woman’s safety.
- Consider emptying or filling the pool. This will depend on the clinical situation.
Please refer to Appendix 2 for ‘Procedure for removal of a woman from the pool if she is unable to do so herself’.
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Women should be asked to exit the pool if any concerns arise. This includes:
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Women should be asked to exit the pool and low risk care should continue until it is appropriate to re-enter the pool:
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PROCEDURE FOR MOVING OF A WOMAN FROM THE POOL, IN A HOSPITAL SETTING, WHEN SHE IS UNABLE TO DO SO FOR HERSELF:
Staff should ensure the safe evacuation of a woman from a birthing pool to commence resuscitation procedure.
Summon help: Midwife should support the woman’s head to ensure her face is clear of water and maintain her airway. The emergency buzzer should be utilised and 2222 should be called to initiate a crash call.
Equipment to be used:
- Trolley/bed
- Evacuation Net
- Slide Sheets
Minimum members of staff required to facilitate full evacuation, with the use of equipment – four
- DO NOT DRAIN THE POOL, considering filling pool further – The buoyancy offered by the water will assist staff to position the net, and to support and turn the woman.
- Staff member to prepare the trolley/bed in suitable position to receive the woman.
- Slide sheets should be placed on the trolley/bed to assist with sliding woman onto the trolley/bed.
- Two members of staff will position the evacuation net under the woman.
- The midwife must move to one side of the woman but remain in charge of the airway.
- Using clear commands e.g., “Ready, Steady, Slide”, slide the woman clear of the pool and onto the trolley/bed.
- Remove the net and the slide sheets from under the woman once she is safely located on the trolley/bed.
- Keep the woman warm with towels/blankets and assess.
PROCEDURE FOR REMOVAL OF A WOMAN FROM THE POOL, IN A HOMEBIRTH OR STAND-ALONE SETTING, WHO IS UNABLE TO DO SO FOR HERSELF:
It is important to utilise all personnel available which may include birth partner/s to facilitate evacuation process. It is likely that if evacuation is required, it is for resuscitation and so paramedic assistance is always required.
If there is only one midwife present (e.g., during first stage of labour) –
- Apply a maternal neck float in order to keep her head out of the water.
- Call 999 “Immediate threat to life”.
If there are two midwives present –
- One midwife to hold the woman’s head free from the water and apply neck float
- Second midwife should call 999 “Immediate threat to life”.
The first midwife applying a neck float when there are two midwives present allows for them to be free to assist with the evacuation. If there is no neck float available the steps should be followed, with a midwife supporting the woman’s head to ensure it remains clear of the water.
If the birthing pool in use is a ‘birth pool in a box’ (the most common type of birthing pool), once help has been called for, deflate the top and middle segments of the pool (if there are two Midwives present only deflate the middle section, due to the spillage which occurs with deflating two sections). When the segment(s) are deflated, the woman can then be removed from the pool by sliding over the remaining inflated segment(s) of the pool. This can be done, only in an emergency, by a single practitioner. However, as stated above it is important to make use of all personnel available including birthing partner/s to assist in the evacuation of the woman. Once the woman is out of the pool, assess and commence resuscitation as required.
Note if birthing pool is a la bassine, which has interconnecting vertical columns rather than circular compartments, they may not deflate individually. In an emergency, slowly deflate and attempt to maintain shape with pressure on top, in order to try to keep some of the water in.
There are no nets available when in a homebirth setting. There are, in most Home birth kits, neck floats available for use. Women are made aware of this when requesting the use of a pool at home. They are made aware of the difficulty of evacuation and that their partners and/or ambulance staff may be required to assist. Note, the Homebirth Team have never had to put an evacuation into practice at home as women would be advised to leave the pool early if in any way unwell. For example, feeling light-headed/bleeding/MEWS red score.
When evacuating a woman at home, be mindful of electrical equipment nearby.
Aim: To support Water Immersion for Labour and Birth for all low risk women, promoting uninterrupted physiological labour and decreasing pharmacological analgesia.
STANDARD OPERATING PROCEDURE - Care of Women choosing Water Immersion for Labour and Birth (pdf)