Oxford Handbook of Midwifery (55 page)

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Authors: Janet Medforth,Sue Battersby,Maggie Evans,Beverley Marsh,Angela Walker

BOOK: Oxford Handbook of Midwifery
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  • Hospital routines and unnecessary medical terminology should be kept to a minimum.
  • Women should be encouraged to make a birth plan regardless of their parity, obstetric status, or mode of delivery, to ensure that their individual wishes are taken into account.
  • Hospital birth may take place in a consultant-based unit, a midwifery-led birth suite, or a birth centre near to a hospital base.
  • All maternity units should have a policy for the care of low-risk women within the hospital environment.
    Recommended reading
    National Institute for Health and Clinical Excellence (NICE) Guidelines (2007).
    Intrapartum Care: Management and Delivery of Care to Women in Labour CG55
    . London: NICE. Available from: M
    http://guidance.nice.org.uk/CG55 (accessed 22.2.11).
    1. Peel Report (1970).
      Report of the Standing Maternity and Midwifery Advisory Committee (Chairman Sir John Peel)
      Domiciliary Midwifery and Maternity Bed Needs. London: HMSO.
    2. Tew M (1990).
      Safer Childbirth
      —
      A Critical History of Maternity Care
      . London: Chapman and Hall.
      CHAPTER 11
      Normal labour: first stage
      220‌‌
      Water birth
      Labouring in water is recognized as an appropriate method of assisting pain relief and relaxation, by the release of natural endorphins, raising oxytocin levels, and reducing catecholamine secretion. Water provides a secure, peaceful environment and aids buoyancy, which enables the woman to adopt positions of comfort and freedom more easily. There have, however, been several controversies regarding the use of water for giving birth such as: risk of fetal drowning; fetal hyperthermia; length of labour; genital tract trauma; use of analgesia; Apgar score; and blood loss. Birthing in water is associated with fewer third- and fourth-degree tears, however, labial tears, associated with naturally occurring trauma are more likely to occur.
      1
      Studies have found that there is no difference in the length of labour,
      2
      blood loss,
      3
      Apgar scores, or risk of infection
      4,5
      when using a birth pool.
      Most maternity units have specific guidelines to ensure safe practice regarding water birth, while also considering the individual needs of the woman. Midwives should familiarize themselves with this mode of birth to ensure their competency when a woman chooses to labour or give birth in water.
      Criteria
      • Single cephalic presentation.
      • Uncomplicated term pregnancy from 37 weeks until term +9–14 days, dependant on hospital policy.
      • Woman’s informed choice.
      • Spontaneous rupture of the membranes of less than 24h.
      • It may be appropriate for the mother to use the pool for the first stage only—maternal choice or anticipation of possible problems in the second stage, e.g. previous shoulder dystocia or previous PPH.
        Exclusion
      • Intrauterine growth retardation.
      • Meconium-stained liquor.
      • Following the administration of narcotics (pethidine, diamorphine), midwives need to use their discretion and professional judgement, and refer to their local guidelines, regarding re-entry to the pool. A
        minimum of 3–12h for diamorphine has been suggested.
      • Intravenous infusion.
      • Previous LSCS—not a universal exclusion, depends on the reasons for the LSCS, a risk assessment is advisable.
      • Antepartum haemorrhage.
      • Multiple pregnancy.
      • Prolonged rupture of membranes of over 24h.
      • Grand multiparity.
      • Maternal pyrexia—37.5 or above.
      • Epilepsy.
      • Fetal heart rate abnormalities—bradycardia, tachycardia, decelerations.
    WATER BIRTH
    221
  • Any fetal or maternal finding during the course of labour and birth that deviates from normal, or where continuous CTG is required.
  • Women should be able to enter and leave the pool independently— this may result in exclusion of some women with disabilities or poor physical mobility on safety grounds. A risk assessment is advisable.
    Preparation for water birth
  • There will be local policies in place for effective cleaning and preparation of the pool. Decontamination should involve the use of a chlorine-releasing agent which is effective against HIV, hepatitis B, and hepatitis C.
  • If the pool has not been used for some time, leave the water to run for a minimum of 5min.
  • Use a previously disinfected hose for each woman using the pool.
  • Fill the pool to about two-thirds depth, approximately to the woman’s breast level and sufficient to cover the uterus when in a sitting position.
  • Maintain a temperature of between 35 and 37°C in the first stage of labour to avoid fetal hyperthermia, frequent observation of the pool temperature is therefore crucial. You may need to add hot water every 30min to achieve this.
  • The following equipment should be available:
    • Thermometer to check the water temperature
    • Waterproof Sonicaid
    • Towels
    • Sieve for pool to remove debris
    • Patient hoist to be placed outside the pool room door
    • Sample bottles for microbiology checks on the pool water—refer to local guidelines
    • Portable Entonox or extended tubing for the woman to use while in the pool.
  • Wear loose, comfortable clothing, and gauntlet gloves (or half a size smaller gloves) for the birth.
  • Encourage involvement of the birth partner. If the partner wishes to enter the pool then suitable swimwear should be used.
  • Adhere to health and safety principles while caring for a woman in the pool.
    Care in the first stage of labour
  • Allow the woman to enter and leave the pool as she wishes.
  • The woman should be in established labour prior to entering the pool, i.e. 4–5cm dilated. Entering the pool too early is associated with slowing progress during labour.
    5
  • Check the woman’s temperature hourly, to help prevent fetal hyperthermia. A rise of 1°C above the baseline should indicate possible termination of pool use.
    6
  • Check the pool water temperature half-hourly and top up to maintain pool temperature as appropriate. Record pool temperature on the partogram and in specified paperwork for pool use.
    CHAPTER 11
    Normal labour: first stage
    222
    • Assist the woman in adopting a comfortable position.
    • Avoid dehydration by encouraging the woman to drink freely. Diuresis is increased when immersed in water.
    • Rehearse with the woman and her birth partner, the principles of vacating the pool in the event of an emergency, with regard to health and safety.
    • Amniotomy and spontaneous rupture of the membranes (SROM) are not contraindicated if all other observations, progress, and criteria are satisfactory.
    • It is possible to perform a vaginal examination while the woman is in the pool; however, this needs to be discussed with the woman and will depend on individual preferences.
    • There are differences of opinion regarding the use of essential oils, generally they are not added to the pool—refer to local guidelines and information on administration of oils (b see Aromatherapy during labour, p. 248).
    • Adhere to the guidelines for low-risk care during labour.
      Care in the second stage of labour
    • Continue with low-risk care as recommended.
    • Adjust water temperature to 37°C and check pool temperature every 15min if birth in the pool is anticipated.
    • Hands-off approach for the birth—touching the head is thought to stimulate the breathing response.
    • A pool birth should be facilitated completely under water, to avoid premature cessation of the breathing response. No increase in perinatal morbidity or mortality has been found when comparing births in water and conventional vaginal births in low-risk women.
      7
    • If at any time during birth the baby is exposed to air, then the baby must be born out of water.
    • Once the head is delivered it is usually visible as a dark shadow under the water. Do not check for the cord routinely. If the baby is not delivered with the next contraction and the cord does require
      clamping and cutting, the woman should be eased out of the water on to the pool edge to undertake the procedure. The baby must then be born out of water.
    • Allow the remainder of the body to deliver spontaneously; it may be
      appropriate to assist/encourage the woman to bring the baby to the
      surface herself, with the baby’s face uppermost. Assistance to deliver the shoulders can be utilized in the same way as a birth out of water.
    • If episiotomy is required, assist the mother to sit on the ledge or to get out of the pool for the procedure.
    • Due to the more gentle birth, babies born in water often do not cry or appear to breathe instantaneously. The usual checks of the baby’s colour, respiration, and heart rate should be observed. If there is any cause for concern, then the baby may be rubbed with a towel or lifted into the cooler air out of the water and this will usually result in a crying response.
    • Cut and clamp the cord promptly (to avoid the risk of neonatal polycythaemia) before the mother leaves the pool. The vasoconstriction action of the cord may be delayed while in the water.
      WATER BIRTH
      223
      The third stage of labour

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