ICID > Clinical Management > Maternity Neonatal > Underwater Labour and Birth  

Underwater Labour and Birth 

  • 1. Indications
  • 2. Clinical Management
  • 3. Patient Information
  • 4. Audit
  • 5. Evidence Base
  • 6. Appendices
  • 1. Indications

    1.1 Background

    The use of water as a method of pain relief for women with low risk pregnancies is supported by NICE 2007, the RCOG 2006 and RCM. It is important that the decision to use water as a method of pain relief is made as part of a holistic care plan with the woman and her birth partner. Women must be properly counselled by midwives and obstetricians surrounding the risks and benefits of laboring in water to enable them to make a fully informed decision. NICE (2007) suggests that women are informed that there is insufficient evidence of a high enough quality to either support or discourage women from using water in labour.

    A Cochrane review of 12 trials surrounding the use of water in labour found that this can reduce the need for epidural analgesia (38% in the water immersion group vs 42% in the control group). (Cluett E,R and Burns, E 2012). These trials included data from 3243 women (Cluett E,R and Burns, E 2012) The majority of the trials (8) focused on the first stage of labour and found that the duration of the first stage was reduced by a mean of 32 minutes (Cluett E,R and Burns, E 2012)

    Labour outcomes were also compared and there was no difference found in assisted vaginal deliveries or caesarian sections, the use of oxytocin to augment labour, perineal trauma or maternal infections. The trials also compared the outomes for babies of which there was no difference found in neonatal unit admissions and infections or apgars of less than 7 at 5 minutes. (Cluett E,R and Burns, E 2012)

    Qualitatively, one trial of the second stage of labour found that women expressed a significantly higher level of satisfaction with the birth experience (Cluett E,R and Burns, E 2012)

    Benefits of labour in water

    • Provides an environment that offers an alternative form of pain relief, which may reduce the need for other forms of analgesia such as epidural (Cluett E,R and Burns, E 2012).

    • Enables the labouring woman to have free movement and choice of position, thus allowing the calming effect of being immersed in warm water to aid relaxation. (Church 1989 cited Walker-Illig 2006)

    • Provides a non-clinical and tranquil environment for the labouring woman and her partner.

    • May speed up the first stage of labour (Cluett E,R and Burns, E 2012)

    • May reduce blood pressure

    Potential risks of delivery in water

    • Difficulty in taking emergency measures should a problem develop while the woman is in the bath.

    1.2 Aim/purpose

    To ensure the provision of evidence based care and a safe environment for women who opt to use the birthing pool in labour.

    1.3 Patient/client group

    Low risk women contemplating and/or using the birthing pool for labour or birth.

    1.4 Exceptions/ contraindications

    Women who do not meet the criteria for use of the pool as outlined below.

    1.5 Options

    There are two birthing pools available on labour ward.

    2. Clinical Management

    2.1 Staff & equipment

    Waterproof sonicaid, hoist.

    2.2 Use of the pool

    2.2.1 Criteria for use of the water birth pool in labour

    The aim is that Midwives will be able to provide safe and appropriate care for a woman requesting to labour in water and who may subsequently choose to deliver underwater.

    The Midwife’s clinical judgement is paramount

    Labouring women may use either pool if they are in 'normal', uncomplicated labour. This is defined as follows:-

    • uncomplicated pregnancy between 37 weeks and 42 weeks gestation (Lakin et al 2014).

    • singleton pregnancy, cephalic presentation

    • no known medical problems, such as epilepsy or diabetes

    • no sedation should have been administered within the last four hours (excluding entonox)

    • mildly hypertensive women with a diastolic of no more than 90mmHg may use the bath, as immersion in water has been shown to reduce blood pressure (Lakin et al 2014)

    • induction of labour for postmaturity in low risk women.

    Known obstetric complications, such as those listed, may prevent a woman being able to deliver in the pool, however they may not all prevent labouring in water. Each woman should be assessed individually by the obstetric team and further discussion is needed (Lakin et al 2014) Woman under consultant care due to high risk pregnancies who are eligible to use water are still to remain under consultant care (Lakin et al 2014).

    • recurrent antepartum haemorrhage

    • preterm labour

    • pre-eclampsia

    • significant PPH

    • previous shoulder dystocia

    • suspected infection as indicated by pyrexia/maternal tachycardia

    • thick particulate meconium stained liquor

    • BMI >40

    • augmentation with syntocinon

    Women with a BMI of over 35 at booking should be informed that their suitability for labouring and or delivering in water will be individually assessed as to their ability to leave the pool in an emergency. Women with a BMI above 40 at booking will not be able to labour or deliver in water.

    Some women who are deemed more “high risk” may be able to labour and or deliver in the pool with telemetry monitoring of the fetal heart. A plan of care should be documented in their notes.

    • Thin meconium stained liquor

    • VBAC

    • Known IUGR

    2.2.2 Preparation of the pool – please follow Salisbury NHS Foundation Trust Health and Safety, and Infection Control Policies.

    • Prepare room for birth, ensuring all necessary equipment is ready.

    • Ensure emergency equipment is accessible, e.g. hoist and lifting devices.

    • Ensure no electrical equipment is near the pool.

    • Clean the bath according to infection control policy. NB. - the pool should be cleaned DAILY regardless of whether it is to be used or not.

    • The pool should be filled to approximately two thirds full, sufficient to cover the woman’s abdomen. There is no evidence that the water temperature should be kept at body temperature but should be dictated by the woman’s comfort. However it should never be above 37.5 degrees centigrade.

    • Hourly pool temperature should be recorded and documented in the partogram.

    • Aromatherapy, hypnobirthing and entonox can be used whilst the woman is in the pool. (Lakin et al 2014). NICE 2007 states that women must not enter the pool within 2 hours of opioid analgesia being administered.

    2.2.3 The First Stage of Labour

    There is no evidence to suggest that women should be in established labour prior to entering the pool or that water slows down labour. However it may be beneficial after 2 hours of immersion to suggest a change of environment such as getting out and walking around. After 30 minutes out of the pool, re-entering the pool can cause a sudden increase in natural oxytocin production (Harper 2006)

    • Before allowing the woman to enter the pool the midwife should again remind her and her partner of the possible risks and benefits of using the pool to ensure that they have made an informed choice.

    • Clarify, again, that the woman may be asked to get out of the pool if her labour deviates from the normal, or if she requires any analgesia other than Entonox.

    • Obese women should be informed of any midwifery concerns about their ability to get out of the pool in an emergency.

    • The pool should be rinsed and the taps run for 2 minutes with cold water prior to filling (Active birth pools)

    • The labour notes should be maintained, noting the time the woman enters and leaves the pool

    • Once in the pool the woman should not be left alone – either the midwife or partner should be with her at all times. (Lakin et al 2014)

    • Maternal observations should be documented as per requirements for all women in labour. In addition hourly maternal temperature and hourly pool; temperature should be recorded. NICE 2007). Pool temperature must not exceed 37.5°C (NICE 2007) This will avoid the risk raising the woman’s core temperature, which can in turn lead to maternal exhaustion.

    • Observations of fetal wellbeing should be carried out according to established midwifery practice, i.e. ¼ hourly, immediately following contractions for at least one minute, once in established labour. (NICE 2007) There is a waterproof sonicaid for this purpose.

    • Good maternal fluid intake should be encouraged, especially if the room gets hot, to prevent dehydration and isotonic drinks may be more beneficial than water (NICE 2007). Women are also supported to eat a light diet if they wish (NICE 2007)

    • Women should be encouraged to leave the pool and empty their bladder every 2 hours as per local guidelines. (Harper 2006)

    • The water MUST be kept clear in order to ensure clear vision, minimise infection and avoid inhalation of particles by the baby at the time of the birth (Harper 2006)

    2.2.4 The Second Stage of Labour

    • Maternal and fetal observations should be carried out as normal according to local practice (NICE 2007).

    • It is only necessary to have two Midwives present for the birth if teaching / sharing skills.

    • In order to reduce the risk of fetal stimulation and thus water inhalation, the baby must be completely immersed under the water for the birth and a ‘no touch’ technique should be adopted.

    • The baby must be born completely underwater with no air contact until the head is brought to the surface, as air temperature may stimulate fetal breathing and lead to water aspiration. If a change in position during delivery causes the baby’s head to come in contact with air, the birth should be completed in air. (Harper 2006)

    • The baby must be brought to the surface immediately following birth, head first to reduce the risk of water inhalation.

    • Spencer Wells should be available in case a “snapped cord” occurs.

    • Under no circumstances should a tight nuchal cord be clamped and cut underwater. The mother should be asked to stand up so that the baby's head is out of the water and the cord clamped and cut in the usual way.

      The baby's head should not be allowed to re-enter the water once it has surfaced.

    • Once breathing is established, the baby's body remains submerged while the head is supported above the water. (Harper 2006) The temperature of the water should be monitored every fifteen minutes whilst the baby remains in the pool to reduce the risk of neonatal hypothermia.

    2.2.5 The Third Stage of Labour

    • The third stage can be conducted physiologically, or managed actively following appropriate guidelines.

    • There is no evidence to suggest that it is unsafe to deliver the placenta in the pool.

    • Blood loss should be estimated as less than 500ml or more than 500ml. Any clots should be collected.

    • After the birth, care should continue in the normal way, according to local practice.

    • Full, accurate and legible records should be completed as normal. The time the mother entered and left the pool should be noted. In addition it should be recorded on E3 if a woman has laboured and or given birth in water.

    • The bath should be cleaned after use following the infection control policy. This is the responsibility of the attending midwife. (Don’t forget the mirror if used)

    • The drainage system should be kept closed when the pool is not in use (Active birth pools)

    2.3 Potential complications / Risk Management

    • There is an emergency call bell next to the bath, which is audible throughout the labour ward.

    • There is a resuscitaire available for use in close proximity to either pool.

    • There is easy access to piped oxygen and suction.

    • There are net slings to use should the woman need assistance to leave the pool.

    In an emergency situation, such as maternal collapse or haemorrhage, the woman should be helped out of the water using a net sling. The water should not be drained as its buoyancy will assist in getting the woman out of the pool.

    If shoulder dystocia occurs, drain the bath immediately and proceed as per shoulder dystocia guideline, or take action as above.

    All midwives are responsible for maintaining their own safety when caring for a woman in the pool and assessing the ergonomics of delivering midwifery care. Any concerns should be raised immediately with the midwife in charge and their line manager or supervisor.

    2.4 After care

    Nil specific.

    3. Patient Information

    Use of the birthing pool is discussed in preparation for parenthood sessions.

    4. Audit

    4.1 Audit Indicators

    Implementation of this guidance will be monitored through audit of the following specific standards as a minimum.

    100% of women labouring/giving birth in the birthing pool will have documented evidence of regular fetal and maternal observations in the partogram

    100% of women labouring/giving birth in the birthing pool will have documented evidence of regular water temperature observations in the partogram.

    The annual audit will be a retrospective review of 1% of all health records of women who have had a water birth.

    A member of the midwifery or obstetric teams will conduct the audit.

    The audit findings will be presented to the Maternity and gynaecology audit feedback forum annually.

    This guideline will be reaudited on an annual basis, or after six months if the previous audit results demonstrated compliance of <75%, thus ensuring the action plans from the previous audit have been implemented

    5. Evidence Base

    5.1 Sources of information

    1. Active birth pools, Cleaning & disinfecting your water birth pool (infection control). Available from [http://activebirthpools.com/research/cleaning-disinfecting-your-water-birth-pool]

    2. Alderice,R; Renfrew,M; and Marchant,S 1995 Labor and birth in water in England and Wales; Survey report. British Journal of Midwifery 3 p375-382

    3. Burns E. 2001 Waterbirth. Midirs Midwifery Digest Vol 11 No 3

    4. Church, L. K. (1989). Water birth: One birthing center's observations. Journal of Nurse-Midwifery, 34(4), 165-170. Cited: Walker-Ilig and Windsor, L 2006. Available from: [http://www.activebirthpools.com/wp-content/uploads/2014/05/A-Survey-of-Womens-Experiences-with-Waterbirth.pdf]

    5. Cluett, ER and Burns, E., 2012. Cochrane Summaries – Immersion in water in labour and birth – 2012. Available from: [http://activebirthpools.com/research/immersion-in-water-in-labour-and-birth-cochrane-summaries]

    6. Garland D. and Jones K 2000. Waterbirth: supporting practice with clinical audit. Midirs 10(3) 333-336

    7. Garland D. 2002 Collaborative waterbirth audit – “Supporting practice with audit”. Midirs Midwifery Digest Vol12 No 4 pages 508-511

    8. Harper B 2002 Taking the plunge: reevaluating water temperature. Midirs Midwifery Digest, Vol12 No 4 p505-508

    9. Harper B. 2006 Guidelines for a Safe Waterbirth. Waterbirth International http://activebirthpools.com/research/3000]

    10. Lakin,F, J, Ross and J, Gandy., 2014 Guideline for the use of water immersion for labour and/or birth. Nottingham university Hospitals NHS trust. Available from: [http://www.nuh.nhs.uk/healthcare-professionals/clinical-guidelines/ ]

    11. Nikodem VC. 2003 Immersion in water in pregnancy, labour and birth (Cochrane Review). In: The Cochrane Library, Issue 3. Oxford: Update Software.

    12. Richmond H. 2003 Theories surrounding waterbirth. The Practising Midwife, Vol6 No 2 pages 10-13

    13. Royal College of Obstetricians and Gynaecologists/Royal College of Midwives 2006 Joint statement No 1

    14. NMC 2004. Midwives rules and standards.. NMC, London.

    15. National Institute of Clinical Excellence., 2007 Intrapartum care. NICE. Available from: [http://www.nice.org.uk/guidance/cg190/chapter/Introduction]

    16. National Institute of Clinical Excellence., 2015. Intrapartum care: care of healthy women and their babies during childbirth. NICE. Available from: [http://www.nice.org.uk/guidance/cg190/chapter/1-Recommendations]

    5.2 Summary of evidence, review and recommendations

    6. Appendices

    Document Owner Susan Howard 
    Review Date
    Document Status
    Revision Number