INTRODUCTION:

Pain is a complex, personal, subjective, multifactorial phenomenon which is influenced by physiological, biological, sociocultural and economic factors.

Labour pain is as one of the most severe pain known to mankind and exclusively suffered by womankind.

The therapeutic properties of warm water immersion have been known for centuries. Baths, showers and whirlpools have been used for comfort during labor for many years. Over the past two decades the use of warm water immersion for the birth of the baby has aroused interest in many countries and an increase in the number of women requesting this option for both hospital and out-of-hospital births is occurring. Those advocating labour and/or birth in water argue that buoyancy in water helps women to relax and the warmth may help to reduce pain. For women using birthing pools rather than conventional baths there may also be greater ease of movement ¹. It is also argued that use of a birthing pool offers greater privacy and a more holistic experience. A systematic review comparing labour in water with conventional labour (988 women) found no clear differences in either benefits or adverse effects between the two options ².

In 1990, the Scientific Advisory Committee produced a statement on birth under water, emphasizing the need for scientific study. This statement was revised in 1994, following a period of intense media interest in the safety of labour and birth in water. The need for appropriate information about the benefits and risks of birth in water and its level of use throughout the country was again highlighted^{. 3}

Waterbirth International has reviewed the best available evidence and offers this guideline to assist midwives and women in their decision making process around the use of water immersion for labor and birth ^.The body of evidence is small but growing. Water birth is simple. Within the simplicity of water, labor and birth lies a complexity of questions, choices, opinions, research data, women’s experience and practitioner observations⁴.

Definition:

It is a method of giving birth to a child in a bath tub or pool with full of warm water.

Water immersion must be defined at providing a depth of water which enables the mother to sit in water that covers her belly completely and comes up to her breast level or kneel in water on her haunches which comes up to just below her breast level. Any amount of water less than this does not constitute true immersion and will not create the buoyancy effect and produce the chemical and hormonal changes which enhance a more rapid labor. After an initial immersion of approximately thirty minutes the body responds by releasing more oxytocin, but only if the body experiences deep immersion, leading to buoyancy⁴.

Factors support Newborn for birth in water:

Several inhibitory factors prevent a baby from inhaling water at the time of birth. These inhibitory factors are normally present in all newborns.

Increased PGE2 Level:

The baby in utero is oxygenated through the umbilical cord via the placenta, but practices for future air breathing by moving his/her intercostal muscles and diaphragm in a regular and rhythmic pattern from about ten weeks gestation on. The lung fluids that are present are produced in the lungs and are similar chemically to gastric fluids. These fluids come up into the mouth and are normally swallowed by the fetus. There is very little inspiration of amniotic fluid in utero. Twenty-four to forty-eight hours before the onset of spontaneous labor, the fetus experiences a notable increase in the prostaglandin E2 levels from the placenta which causes a slowing down or stopping of the fetal breathing movements (FBM).With the work of the musculature the diaphragm and intercostal muscles suspended, there is more blood flow to vital organs, including the brain. You can see the decrease in FBM on a biophysical profile, as you normally see the fetus moving these muscles about 40 percent of the time. When the baby is born and the prostaglandin level is still high, the baby’s muscles for breathing simply don’t work, thus engaging the first inhibitory response⁵.

Hypoxia:

A second inhibitory response is the fact that babies are born experiencing acute hypoxia or lack of oxygen. It is a built-in response to the birth process. Hypoxia causes apnea and swallowing, not breathing or gasping. If the fetus were experiencing severe and prolonged lack of oxygen, it may then gasp as soon as it was born, possibly inhaling water into the lungs. If the baby were in trouble during the labor, there would be wide variability noted in the fetal heart rate, usually resulting in prolonged bradycardia, which would cause the practitioner to ask the mother to leave the bath prior to the baby’s birth ⁶.

Temperature variation-:

The temperature differential is another factor thought by many to inhibit the newborn from initiating the breathing response while in water. The temperature of the water is so close to maternal temperature that it prevents any detection of change within the newborn. This is an area for reconsideration after increasing reports of births taking place in the oceans, both now and in eras past. Ocean temperatures are certainly not as high as maternal body temperature, yet babies that are born in these environments are reported to be just fine. The lower water temperatures do not stimulate the baby to breathe while immersed ^6.

Hypotonic solution of water:

One more factor that most people do not consider but which is vital to the whole waterbirth and aspiration issue is the fact that water is a hypotonic solution and lung fluids present in the fetus are hypertonic. Even if water were to travel in past the larynx, it could not pass into the lungs based on the fact that hypertonic solutions are denser and prevent hypotonic solutions from merging or coming into their presence.

Larynxial reflex:

The last important inhibitory factor—the dive reflex—is associated with the larynx. The larynx is covered all over with chemoreceptor, or taste buds. In fact, the larynx has five times as many taste buds as the whole surface of the tongue. When a solution hits the back of the throat and crosses the larynx, the taste buds interpret what substance it is and the glottis automatically closes; the solution is then swallowed, not inhaled⁷.

God built this autonomic reflex into all newborns to help them breastfeed, and it is present until about the age of six to eight. Newborn is very intelligent and can detect what substance is in its throat. It can differentiate between amniotic fluid, water, cow’s milk or human milk. The human infant will swallow and breathe differently when feeding on cow’s milk or breast milk due to the dive reflex. All these factors combine to prevent a newborn who is born into water from taking a breath until he is lifted up into the air.

Initiation of first breath of newborn:

As soon as the newborn senses a change in the environment from the water into the air, a complex chain of chemical, hormonal and physical responses initiate the baby’s first breath. Water born babies are slower to initiate this response because their whole body is exposed to the air at the same time, not just the caput or head as in a dry birth. Many midwives report that water babies stay a little bit bluer longer, but their tone and alertness are just fine. It has even been suggested that water born babies be given the first APGAR scoring at one minute thirty seconds, not at one minute, because of this adjustment.

Several things happen all at once in the baby. The shunts in the heart are closed; fetal circulation turns to newborn circulation; the lungs experience oxygen for the first time; and the umbilical cord is stretched causing the umbilical arteries to close down. The newborn born into water is protected by all the inhibitory mechanisms mentioned above and is suspended and waiting to be lifted out of the water and into mother’s waiting arms. All the fluids present in the lung alveoli are automatically pushed out into the vascular system from the pressure of pulmonary circulation, thus increasing blood volume for the newborn by one-fifth (or 20 percent). The lymphatic system absorbs the rest of the fluids through the interstitial spaces in the lung tissue. The increase of blood volume is vital for the baby’s health. It takes about six hours for all the lung fluids to disappear ⁸.

Reviews on maternal and fetal outcomes of labor and birth in water:

Risks and concern:

No study reveals water birth is associated with higher maternal and fetal risk such as infant mortality and morbidity rate than air birth.

A study carried out in Liverpool, UK, compared 100 women who used a birthing pool at some point during their labour with one hundred women who laboured and gave birth on land. The babies born to the women who used the pool were just as healthy as the babies born to the women who laboured on dry land. None of the babies in either group needed to spend any time in the special care baby unit^9.

A study conducted in England between 1994 and 1996 on the outcomes of 4,032 births in water. Perinatal mortality was 1.2 per 1,000, but no deaths were attributed to birth in the water. Two babies were admitted to special care for possible water aspiration ^10
.Between 1985 to 1999,among 150,000 water birth worldwide no valid report was reported on infant mortality due to water aspiration or inhalation. In the early days of water birth a baby was reported to have died from being born in the water. This particular newborn death was caused not by aspiration, but by asphyxiation because the baby was left under the water for more than fifteen minutes after the full body was born. At some point the placenta detached from the wall of the uterus and stopped the flow of oxygen to the baby. When the baby was taken out of the water, it did not begin breathing and could not be revived. On autopsy the baby was reported to have no water in the lungs and its death was attributed to asphyxia ¹⁰.Although there have been one or two reports of babies who have died of waterlogged lungs, this seems to have been because they were kept underwater for a long time after birth, rather than being brought to the surface immediately.

A study was conducted in UK by comparing the perinatal mortality rate among water birth babies with other low risk births in the . This study tried to estimate mortality and morbidity rates for babies delivered in water and reported five perinatal death. None of the five perinatal deaths recorded among the waterbirths was attributable to delivery in water. Admissions to special care baby units were slightly lower for the water-born babies than admissions for other low-risk babies ¹⁰.This was a landmark study in providing significant reassurance about the safety of waterbirth.

A first study conducted in Hyderabad, India on maternal and neonatal health in Waterbirth. Studies found that when babies are born under water, they require less oxygen immediately after birth. This has been shown to increase oxygen supply to the brain, kidneys and liver, giving lifelong benefit to the baby. It is concluded that water has been used over the ages to for labor and during actual childbirth. On closer examination, the baby is surrounded by amniotic fluid all throughout its stay in the womb. Waterbirth considerably eases the baby’s transition from inside her mother’s womb to the outside world. Waterbirth is less traumatic for the baby when it is born from a “watery” environment in the mother’s womb into another “watery” environment, for example in a tub. For the mother too, being in water during labor reduces labor pains substantially, as water has a therapeutic effect on her. At our Natural Birthing Center, The Sanctum, mothers who labor in water, are more calm, and serene. Pushing is less painful in warm water, as the perineal tissues stretch more easily, without giving pain. Our midwives and staff are experts in helping mothers use waterbirthing techniques and give mothers and baby a chance to experience the wonders of water as a birthing ¹¹.

Pain management:

Water birth is an effective form of pain management during labor and delivery. Water birth is a form of hydrotherapy which, in studies, has been shown to be an effective form of pain management for a variety of conditions especially lower back pain (a common complaint of women in labor)¹². In an appraisal of 17 randomized trials, two controlled studies, 12 cohort studies, and two case reports, it was concluded that there was a definite "benefit from hydrotherapy in pain, function, self-efficacy and affect, joint mobility, strength, and balance, particularly among older adults, subjects with rheumatic conditions and chronic low back pain,". When compared with conventional pain management techniques for labor and delivery (e.g. anesthesia and narcotics), hydrotherapy is also possibly a safer alternative. In studies, epidural anesthesia (EDA) is correlated with an increased rate of instrumental (e.g. forceps in childbirth) delivery rates and also cesarean section rates . Full immersion in water promotes physiological responses in the mother that reduce pain including a redistribution of blood volume, which stimulates the release of oxytocin and vasopressin , the latter which also increases oxytocin blood levels ². The Cochrane Database of Systematic Reviews has found that "the statistically significant reduction in maternal perception of pain and in the rate of epidural analgesia suggest that water immersion during the first stage of labour is beneficial for some women. No evidence was found that this benefit was associated with poorer outcomes for babies or longer labours." It has also been found that in waterbirths the buoyancy of the mother and the baby allow for a gravitational pull. This pull not only opens up the mother's pelvis but also allows the baby to descend more easily 4.

Maternal and neonatal outcomes after water immersion for labor and birth have been assessed in two large surveys over a four year period in England and Wales. Researchers reviewed 4693 and 4032 births, respectively, where water immersion was used and found difference in pain relief for women compared to a cohort group of low risk women who did not use. But no difference was found in neonatal outcome in both group.^10,13

A Systemic review of control trial reported women experienced less pain after water immersion than their non-immersion counterparts and over 80% of the water immersion group said they would use the tub in subsequent labors also, found that using a birthing pool significantly reduces women's use of pain relieving drugs in labour. Women expecting their first babies and who spent some time laboring in water had far less pethidine, and far fewer epidurals, than women who spent all their labour on dry land. The same was true for women who were giving birth to their second or subsequent babies¹⁴.

The control that women gain by being able to move freely in the water often helps them assess their own progress either by feeling the baby’s movements more intensively or actually being able to examine themselves internally. Women report that the water intensifies the connection with the baby at the same time that it reduces the pain. They can feel the baby move, descend and push through the birth canal. The prospect of the midwife becoming an active observer increases as mothers have the ease of mobility in the water and assume more and more responsibility for the birth. For many reasons, including reducing the risk of infection for the provider, many midwives suggest a hands-off birth for the mother. The water slows the crowning and offers its own perineal support ¹⁵. This “minimal-touch” approach also gives the mother a greater sense of controlling her own birth.

Intact perineum and decrease episiotomy:

Perineal trauma is reported to be generally less severe, with more intact perineum for multiparas, but in some of the literature about the same frequency of tears for primiparas in or out of the water. One of the best benefits of water birth is the zero episiotomy rate that is reported throughout the literature. It is mentions that episiotomies can be done, but no one else offers this suggestion. The combination of being upright, having the mother in a good physiological position to birth her baby giving her the freedom of control and not telling her to push when her body is not indicating it, all contribute to better perineal outcomes ¹⁶.Other researchers have made similar outcome reports ¹⁴,¹⁷,¹⁸.Water birth is believed to aid stretching of the perineum and decrease the risk of skin tears. Support from the water slows crowning of the infant's head and offers perineal support, which decreases the risk of tearing and reduces the use of episiotomy, a surgical procedure which can cause a number of complications. Indeed, there is a zero episiotomy rate in the waterbirth literature ³. Moreover, "perineal trauma is reported to be generally less severe, with more intact perineums for multiparas, but in some literature about the same frequency of tears for primiparas in or out of the water," ¹²,^{13, 15}

Labour progress:

The Cochrane database reviewed 12 trials (3243 women) and found Water immersion during the first stage of labour significantly reduced epidural/spinal analgesia requirements, without adversely affecting labour duration, operative delivery rates, or neonatal wellbeing. One trial showed that immersion in water during the second stage of labour increased women's reported satisfaction with their birth experience. Further research is needed to assess the effect of immersion in water on neonatal and maternal morbidity. No trials could be located that assessed the immersion of women in water during the third stage of labour, or evaluating different types of pool/bath ³

The highly respected Cochrane database which looks at the evidence from all the best research carried out into maternity care concludes that, 'water birth immersion during the first stage of labour is beneficial for some women', and that, 'immersion during second stage of labour needs further investigation, but at present there is no clear evidence to support or not support a woman's decision to give birth in water’. Although some studies have shown that the first stage of labour tends to be quicker in water, others have not found this to be the case. The Midwives Information and Resource Service in the UK concludes that there still isn't enough evidence to say whether using a birthing pool shortens labour ⁴.

Maternal blood loss:

The inability to accurately assess blood loss in the water is a reason given by some midwives for either not “allowing” the birth to take place in the water or asking mother to get out right away after the baby is born. But blood loss is easy to judge after a few births. A review of water births at Maidstone Hospital in Kent, England, that midwives are much better at judging and reporting blood loss in the water after experiencing over 500 births¹⁹. An useful way to identify the extent of postpartum hemorrhage is how dark the water is getting. A few drops of blood in a birth pool diffuse and cause the water to change color sometime a water proof flashlight comes in handy can be used because dropping a flashlight onto the bottom of the birth pool allows to look for bleeding as well as meconium during the birth. It also helps you spot floating debris so it can be removed.¹⁹

For care providers who are inexperienced in delivery in water, it may be difficult to assess the amount of maternal blood loss. While well-developed methods of determining maternal blood loss in water do exist^], many providers prefer to deliver the placenta "on land" for this reason (e.g. the University of Michigan hospital).On the other hand, some doctors and midwives see that waterbirths have actually been known to reduce the amount of blood loss. The water surrounding the mother actually lowers the mother's blood pressure and heart rate. Mothers still lose significant amount of blood through the passing of the placenta.

Infection:

A study showed no increase in infection for mothers or babies when the babies were born in water, compared with babies who were born on dry land. Most hospitals that promote waterbirth have detailed policies for cleaning birthing pools and the area around the pool, which are followed very carefully. You can be pretty confident that the pool has been thoroughly cleaned before you get into it.²⁰

Infection control, especially in a hospital setting, requires diligence and the attention to strict protocols between and during births. Cleaning and maintaining all equipment used for a water birth will prevent the spread of infection. In a random study conducted at the Oregon Health Science University Hospital, cultures were done from the portable jetted birth pool before, during and after birth, as well as from the fill hose and water tap source. In all instances no bacteria was cultured from the birth pool but the water tap did culture Pseudomonas ²⁰.In a British study of 541 water labors, no serious infections were reported during the three-year period of data gathering. Again, Pseudomonas aeruginosa was the only persistent bacteria discovered in two babies who tested positive from ear swabs. But no treatment was necessary ²¹.

Private space:

The water creates a wonderful barrier to the outside world. It becomes the woman’s nest, her cave, her own “womb with a view.” If the pool is large enough to include her partner or husband, it then becomes an intimate place for the two of them to labor together and experience the love dance of birth. If the midwife or physician wants to do a vaginal examination while the mother is in the water, it is much easier for the mother to refuse. Her mobility allows her to move quickly to the other side of the pool. Vaginal exams can be easily done in the water, but to maintain universal precautions, long shoulder-length gloves need to be worn ^12.

Waterbirth Choice:

Once a woman has experienced a waterbirth she will more than likely want to repeat the experience. To that end, Waterbirth International gets some pretty interesting referral requests from women all over the world. If circumstances have changed and the mother is no longer living in a place where waterbirth facilities or practitioners are readily available, she will go to almost any length to recreate the opportunity to give birth in water. A research project that Waterbirth International has been conducting for ten years is a survey of women who have given birth in water. One question on the survey form asks: “Would you consider giving birth again in water?” With over 1,500 surveys collected, only one woman answered no to that question. On her particular survey she emphatically stated no in bold print with two exclamation points and then drew an arrow down to the bottom of the page where in very small print she wrote, “This is number seven, I’m done ²².

Dr. Lisa Stolper is an obstetrician practicing in the quaint New England town of Keene, New Hampshire. She began offering waterbirth to her clients at Cheshire Medical Center in October 1998. One year later she reported an overall waterbirth rate of 37 percent of all vaginal birth and 33 percent for all births, including cesarean sections. Her hospital has purchased just one portable jetted birth pool, but they use it for the labor of almost 50 percent of their clients. They are now considering installing permanent pools to make them available for more women. Her comment about her job as an obstetrician was, “Waterbirth just makes my job so much easier”²³.

The states that have made the most progress for hospital waterbirth are New York, Maine, New Hampshire, Illinois, Ohio, North Carolina and Massachusetts. Obviously, the East Coast is changing faster than the West Coast. It is surprising to some people when they find out that the whole state of California only has a handful of hospitals that provide waterbirth services. More than two thirds of the birth centers in the United States offer waterbirth as an available option. Mothers who call Waterbirth International wanting advice on how to get their particular hospital to allow them to have a Waterbirth are advised that it takes three ingredients to make policy changes within a hospital setting: 1) a motivated mother; 2) an open and supportive practitioner; and 3) a compassionate nurse manager or perinatal coordinator who is willing to take on the training of staff and the creation of new policy ²³.

Acceptance:

Water birth is accepted and practiced in many parts of the United States, Canada, Australia, and New Zealand, as well as many European countries, including the UK and Germany, where many maternity clinics have birthing tubs. Manyindependent birthing centers and many home birth midwives offer water birth services. At present, water birth is often practiced by those who choose to have a home birth, because the majority of hospitals have not yet installed proper birth pools in their maternity wards. In 2006, Waterbirth international listed more than 300 U.S. hospitals that offered such facilities. In India many birthing centers are tried for water birth and accepted as a safe method of delivery^11.

Benefits of waterbirth:

Waterbirth International has reviewed the best available evidence and offers the guidelines to assist midwives and women in their decision making process around the use of water immersion for labour and birth based on following benefits of waterbirth⁴

· Facilitates mobility and enables the mother to assume any position which is comfortable for labor and pushing

· Speeds up labor

· Reduces blood pressure

· Gives mother more feelings of control

· Provides significant pain relief

· Promotes relaxation and Conserves her energy

· Reduces the need for drugs and interventions

· Protects the mother from interventions by giving her a protected private space.

· Reduces perineal tearing

· Reduces cesarean section rates

· Is highly rated by mothers - typically stating they would consider giving birth in water again

· Is highly rated by midwives

· Encourages an easier birth for mother and a gentler welcome for baby

Theoretical Potential Disadvantages:

· Decrease in uterine contraction strength and frequency, especially if entering the bath too soon

· Neonatal water aspiration

· Maternal hyperthermia may contribute to fetal hypoxemia

· Neonatal hypothermia

· Cord immersion in warm water may delay vasoconstriction, increasing red cell transfusion to the newborn and promoting jaundice

· Blood loss estimation and assessment not accurate

· Neonatal infection may be increase - not supported by the evidence

· Risk of acquiring blood born infection or sustaining back injury for caregiver

Criteria for entering of a water pool:

Many hospitals use the five-centimeter rule, only allowing mothers to enter the bath when they are in active labor and dilated to more than five centimeters. Some physiological data supports this rule, but each and every situation must be evaluated and then judged. Some mothers find a bath in early labor useful for its calming effect and to determine if labor has actually started ²⁴.The water sometimes slows or stops labor if used too early. On the other hand, if contractions are strong and regular with either a small amount of dilation or none at all, a bath might be in order to help the mother relax enough to facilitate the dilation. It has been suggested that the bath be used in a “trial of water” for at least one hour, allowing the mother to judge its effectiveness. Women report that often the contractions seem to space out or become less effective if they enter the bath too soon, thus requiring them to leave the bath. Then again, midwives report that some women can go from one centimeter to complete dilation within the first hour or two of immersion. Deep immersion seems to be a key factor. If the pool or bath is not deep enough, at least providing water up to breast level and completely covering the belly, then the benefits of the bath may be less noticeable. The warm water will still provide comfort and the mother will benefit from being upright, in control and drug free, but full immersion promotes more physiological responses, the most notable being a redistribution of blood volume, which stimulates the release of oxytocin and vasopressin ²⁵.Vasopressin can also work to increase the levels of oxytocin. The immediate pain reduction felt upon entering the bath is quite noticeable.

The chemical and hormonal effects of immersion take effect after no less than twenty minutes and peak around ninety minutes. It is therefore suggested that a change of environment, such as getting out and walking be recommended after about two hours of initial immersion. The midwife can make an evaluation of the mother's condition at that time. Getting back in the water after thirty minutes will reactivate the chemical and hormonal process, including an sudden and often marked increase in oxytocin ².

The following criteria are followed:

· An uncomplicated pregnancy of at least 37 weeks gestation

· Established active labour

· Dilation of cervix at least 5cm

· Descent of presenting part

· Established labor pattern - good regular contractions

· Reassuring fetal heart tones

· Absence of bleeding greater than bloody show

· Spontaneous or on-going labor after misoprostol or Pitocin

Absolute contraindications:

· Pre-term labor

· Excessive vaginal bleeding

· Maternal fever > 100.4, or suspected maternal infection

· Any condition which requires continuous fetal heart rate monitoring

· Untreated blood or skin infection

· Sedation or epidural

· Fearful Attendant

· Inflexibility in the client

Controversial issues in water birth:

Meconium staining in amniotic fluid:

The presence of meconium should be evaluated with fetal well-being and taken by itself as a reason to ask the mother to leave the water. Meconium washes off the baby in the water. Baby can be suctioned as soon as it has been brought to the surface of the water. Some practices are now only limiting thick meconium cases.

HIV, Hepatitis A, B, C, GBS:

Evidence shows that HIV virus is susceptible to the warm water and cannot live in that environment. Proper cleaning of all equipment after the birth needs to be carried out. Hepatitis should be the discretion of the attending medical caregiver. There is absolutely no evidence that GBS positive cases should be asked to leave the water. Most hospitals allow IV antibiotic administration while in the water ²⁷.

Herpes:

Some providers will cover the lesion, especially if it has peaked and is sloughing off. Others will require a cesarean. Some feel it is safer to deliver in the water due to the dilution effect of the water.

Breech or multiple births:

The research study believed that the absence of gravity, the warm water and the buoyancy create the perfect environment for a hands free breech birth. Labor in water for both breech and multiples is well documented and recommended. This should be a client/provider decision ²⁸.

Induction or augmentation:

Many hospital practices will now allow mothers whose labors are initiated by Misoprostal or Pitocin to get in the pool as soon as a labor pattern is established. Some even allow mothers with a Pitocin drip to labor in water, as long as fetal heart rate assessment can be monitored with continuous underwater equipment.

Intrathecal use:

A few hospitals will allow a mother into the water after receiving an intrathecal. Monitoring of the baby is suggested as continuous, but some hospitals allow intermittent monitoring.

VBAC:

As the controversy over vaginal birth after previous cesarean section continues, it has been noted that mothers who labor for subsequent births have a much higher success rate in giving birth vaginally. Some hospitals refuse to allow women into the water because they don't provide water proof continuous fetal monitoring²⁹.

Shoulder Dystocia or Macrosomia:

This is usually considered an obstetric or midwifery emergency by most. Current protocols in most hospitals require the mother who is anticipating a large baby to leave the water. There is mounting evidence that providers find it is easier to assist a shoulder dystocia in the water. It is believed that tight shoulders happen more often because of mom or caregiver trying to push before the baby fully rotates. Better to wait a few contractions, with the head hanging in the water and allow baby to rotate. Because position changes in water are so much easier than dryland, a quick switch to hands and knees or even standing up with one foot on the edge of the pool helps to maneuver baby out. (research indicates that you can't predict shoulder dystocia)

Tight nucal cord:

Under no circumstances should the cord be clamped or cut under the water. Babies can be delivered through the cord and 'unwound' under the water. Be cautious of cord snapping.

Water temperature at time of birth:

Some providers will not allow women to birth in water that is lower than body temperature due to the possibility that the baby will attempt to inhale under the water from a change in temperature. There is no evidence that supports this theory, in fact there is more evidence that now shows that lower water temperatures increase the baby's muscular activity and awareness ³⁰. Water babies are slow to start breathing due to the delay in stimulation of the trigeminal nerve receptors in the face and around the nose and mouth. You must consider the birth of the baby from the time it leaves the water, not from the delivery of the baby into the water. German midwife, Cornelia Enning, states that babies are more vigorous at a temperature around 92-95degrees Fahrenheit. If the mother is comfortable in the water, the temperature is OK for baby with only one restrictive parameter - never higher than 100 degrees fahrenheit.

Placental delivery in water:

There is no reason not to allow the birth of the placenta in water. Objections include inability to judge blood loss, possible water embolism and inability to contain all the byproducts of conception in one place. Evidence now shows that delivery of the placenta is safe, blood loss can be estimated by color evaluation and determination of where the bleeding is arising and there is absolutely no scientific basis for worry over water embolism. Placenta and pieces can be placed in a floating bowl in the water without difficulty. Cutting and clamping of the cord is not recommended with the delivery of the placenta in the water³.

Strategies which may increase safety and women's satisfaction following birth in water:

Control of the water temperature:

The hypothesis is that warm water relaxes the muscles and encourages mental relaxation. This may then improve uterine perfusion, relaxation and contraction, thus leading to less painful contractions and shorter labours. Temperature of the water should be comfortable for the woman, although body temperature (37°C) may be the ideal. Water temperature should not rise above 37°C, however, as there is a risk of circulatory redistribution to the skin and hypotension, possibly leading to decreased placental perfusion. Also, sweating would increase, with a risk of maternal dehydration during a long immersion. Women should be encouraged to drink to prevent dehydration. For the 64 babies identified in the surveillance study, no information about temperature was given for 26 of them (41%)¹⁰. Temperature of the water needs to be carefully controlled and should be regularly measured and recorded.

Keep the pool clean:

During normal delivery the pool may become contaminated by amniotic fluid, blood or faeces. This could lead to an increased risk of neonatal and/or postpartum infection, as well as possibly increasing the risk to staff attending the woman. There has also been concern about possible contamination with pseudomonas as leading to clinical infection ³¹,³². There has been theoretical concern about blood-borne viruses but there is no evidence that this is a problem in practice. In the surveillance study, only three babies were reported to have evidence of infection and one of these was neonatal herpes, which is unlikely to be related to immersion in water. Although the risk of serious infection appears to be low, minimizing contamination of the water by strict adherence to procedures for cleaning pools should help minimize any risk.

Avoid prolonged immersion:

One trial (200 women) compared a policy of entering the bath before 5 cm cervical dilatation with a policy of entering the bath after 5 cm dilatation^.Women who entered the bath early had longer labours and required more oxytocin. They were also more likely to have epidural analgesia. This information should be presented to women, so that they can be encouraged to wait until 5 cm cervical dilatation before entering the bath³³.

Minimize the risk of snapping of the umbilical cord:

An unexpected finding in the surveillance study was that five of the 37 babies (14%) born under water and admitted to special care had a snapped umbilical cord ¹⁰. One baby required transfusion. There are no data on the risk of the cord snapping following normal delivery out of water. A suggested mechanism for the cord snapping was that bringing babies rapidly to the water surface may, if the cord is short, result in greater tension on the cord than for a conventional delivery¹⁰. Strategies suggested for reducing the risk of the cord snapping, although none are supported by evidence, include ensuring the water is not unnecessarily deep during the second stage, bringing the baby gently to the surface and having cord clamps to hand ³⁴.Delivering the baby completely underwater before lifting to the surface has also been suggested. (Yehudi Gordon and Anita O'Neill, personal communication.

Optimize the initiation of neonatal respiration:

Warmth and immersion of the baby's head in water at delivery may lead to inspiratory inhibition. A less pronounced inhibition occurs when the head is raised out of warm water or when water enters the upper respiratory tract. Conversely, cold is a strong stimulator of breathing. This suggests that exposure to cold by removing the baby from the water might optimize the breathing reflex.

Consider using isotonic water:

During a normal delivery, respiration usually begins as the chest is delivered. If delivery is below water the first breath may be before the face is above the surface and water may be inhaled into the lungs. However, physiological data suggest that babies are protected from inhaling while immersed in water, unless they are asphyxiated⁵. Nevertheless, in the surveillance study, 2 of the 37 babies born in water were said to have inhalation of water; described as water aspiration for one and fresh water drowning for the other ¹⁰. Birthing-pool water is likely to be tap water at a lower osmotic pressure than amniotic fluid. If this water is rapidly absorbed it could, in theory, lead to hemodilution and circulatory overload. To reduce this risk it has been suggested that salt could be added to the water, making it more isotonic⁴,³⁵. For a birthing pool holding 909 liters of water, 9 kg of salt would give an isotonic solution³⁵.Normal saline does not stimulate the laryngeal vagal reflex, however, so it may be more likely to be aspirated than water ⁵. There is no evidence about the potential benefits and hazards of this practice and no data on whether salt is being used for birth in water in the UK.

Consider leaving the pool for the third stage:

Warmth has a relaxing effect on uterine muscles that could, theoretically, lead to increased bleeding after delivery of the placenta or possibly retained placenta. The amount of blood lost during delivery may also be difficult to estimate when diluted in the birthing pool water¹¹,¹². Also, if the placenta is delivered under water the combination of vasodilatation and increased hydrostatic pressure could theoretically increase the risk of water embolism. Again, this is a theoretical risk and there is no evidence about whether or not it is a real concern². Until further evidence becomes available it might be prudent to advise women to leave the pool for the third stage.

Have an agreed protocol for dealing with unexpected complications:

If complications develop it is usually necessary for the woman to leave the birthing pool, as it may be impossible to manage the situation in the water. It is important that women are properly informed about the possibility they may be advised to leave the birthing pool. Emergency interventions may be delayed if it is difficult to get the woman out of the bath and appropriate procedures should be developed for dealing with emergency situations. As she leaves the pool the woman should always be adequately supported to ensure she does not slip.

Summary of guidelines for Midwives for practicing water birth:

· Midwives should discuss the potential advantages and disadvantages of water immersion for labor and birth with each woman prior to labor.

· woman’s vital signs and FHR must be within normal limits

· Monitor FHR and vital signs frequently. The fetal heart should be monitored according to accepted guidelines. Use of a waterproof Doppler is recommended.

· Get in to water when contractions are strongly established and the cervix should be at least 5 cms dilated. Water should be between 35-38 degree Celsius.

· Birth positions should be according to the woman’s preference

· Baby should be born completely under water with no air contact

· After birth the baby’s head must be brought to the surface immediately, care should be taken to avoid traction in the cord.

· The woman should be encouraged to maintain adequate hydration and leave the pool to urinate at regular intervals.

· The woman should be asked to leave the water if there are any concerns about her or her baby's well being.

· An alternate birth place should be set up close to the pool.

· Placenta is best delivered outside the tub to assess bleeding. Make warm bath blankets readily available when exiting pool to prevent hypothermia in mother.

· Prevent Hyperthermia in mother

Monitor water temperature in pool with floating thermometer

Can use oral temperature probe with disposable cover

Never exceed 100 degrees Fahrenheit

· The water should be kept as clean as possible. Stool and blood clots should be removed from the pool immediately. The pool should be drained, cleaned and refilled if contaminants cannot be easily removed.

· A small amount of blood often looks like a lot. Undisturbed blood in a pool often congeals at the bottom of the pool into a small clot.

· The pool or tub should be deep enough for the mother to assume any position comfortably. Encourage mother to help guide her own baby out.

· Suturing may need to be delayed due to water saturation of tissues.

· The baby should be born completely underwater with no air contact until the head is brought to the surface, as air and temperature change may stimulate breathing and lead to water aspiration. If a change in position during delivery causes the baby to come in contact with air, the birth should be finished in the air.

· Care should be taken to avoid undue traction on the cord. There have been reports of cord tearing.

· The warm water helps maintain the newborn's temperature to prevent hypothermia. Keep baby submerged with head out only for best heat conservation. Next to mother is best.

· Encourage breast contact immediately, but breastfeeding is not always possible in the water, especially due to water high water levels.

· You can insert a footstool or other object (husband) to raise a mother up high enough after the birth.

· Birth pools should be cleaned completely between uses with a chlorine-releasing agent. All pumps and hoses should also be rinsed with bleach. Small amounts of chlorine or bromine are not harmful to mothers or babies.

· For staff safety, should be instructed to sit or kneel close to birth pool-Use small stool for sitting on outside pool or submerging inside (for mother to raise up) -Use kneeling pads to protect staff knees-Restrict severely obese patients from birthing in the pool- should wear water proof gowns and gloves

· As when caring for any mother or newborn, the midwife is responsible for using her clinical judgment, responding appropriately to problems that may arise, and for documenting her actions.

· Conduct In-service education

A skills check list should be discussed with each staff member in-service educational program is practicing with equipment before direct patient use is advised. A review of intermittent auscultation for nursing staff is advised. All staff should be encouraged to support women in water, but only those nurses who have the desire should actually attend those patients

CONCLUSION:

There are so many areas of water birth to explore. Water birth is more a philosophy of nonintervention than a method or way to give birth. Water birth combines psychology, physiology, technology, humanity and science. Water birth is ancient and yet new at the same time. Water birth embodies a spiritual aspect of birth that is hard to express. Cynthia, who gave birth in water, said it better: “The water made me so completely connected to my body and my baby. The water held me and cradled me so that I could surrender more completely to this amazing and wonderful grace that was happening to me. This is the way that God intended childbirth to be.

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Received on 25.10.2012 Modified on 10.11.2012

Asian J. Nur. Edu. and Research 3(2): April.-June 2013; Page 69-78