The Royal College of Midwives
15 Mansfield Street, London W1G 9NH
Position Paper No 1a
THE USE OF WATER IN LABOUR
AND BIRTH
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Immersion in water during
labour was popularised as a formal method of analgesia by Odent in the 1970s
(Beake 1999), and became widespread after the Winterton Report recommended that
all maternity services provide women with the option to labour or deliver in
water (House of Commons Health Committee, 1992). As with all aspects of
midwifery care, the use of water during labour and birth requires evaluation of
associated benefits and risks, yet there are no large, collaborative,
randomised controlled trials to date (Nikodem, 2000). This paper clarifies the
RCM’s position and recommendations to its members. It should be used in
conjunction with local policies and guidelines.
Introduction
It has been estimated that 50 per cent of maternity
units now provide facilities for labour or birth in water, and that between 15%
and 60% of the women attending those units choose to use these facilities. The
number of births occurring in water is much lower, however; between April 1994
and March 1996, a survey identified only 0.6% of births in England and Wales
occurring in water, 9% of which were home births (Tookey and Gilbert, 1999).
These averages conceal wide variation, with some units passively or actively
discouraging women from using water, while one birth centre reports up to 80%
of women using water during labour, with up to 79% giving birth within the pool
(Beech, 2000).
There is not enough evidence to evaluate the use of
immersion in water during labour (Nikodem, 2000), but both potential benefits
and adverse effects have been described in the literature. Beneficial effects
include maternal relaxation, less painful contractions, shorter labours, less
need for augmentation, less need for pharmacological analgesics, more intact
perinea, and fewer episiotomies (Schorn et al, 1993; Garland and Jones, 2000).
Among the adverse effects discussed are unrealistic labour expectations,
restricted mobility, infection, and the potential problem of the neonate
inhaling water (Alderdice et al, 1995; McCandlish and Renfrew, 1993). The
systematic review produced by the Cochrane Library highlights that ‘although no
significant adverse effects have been reported, the possibility of adverse
outcome for the neonate should not be ignored’ (Nikodem, 2000).
There is clearly a need for more research, and
midwives should give high priority to developing midwifery knowledge in this
area. In the meantime, the available evidence does not justify discouraging
women from choosing this increasingly popular option. Women experiencing normal
pregnancy, who choose to labour or deliver in water, should be given every
opportunity and assistance to do so.
RCM recommendations
1.
All maternity units
should develop policies and guidelines, underpinned by the available evidence,
on the use of water in labour and birth. These should be developed in
consultation with midwives, supervisors, and local user representatives.
2.
Managers and
supervisors should ensure that midwives acquire and sustain the competence,
skills and confidence necessary to assist women who choose to labour or deliver
in water (UKCC, 1992a; UKCC, 1992b; UKCC, 1998a).
3.
Midwives should ensure
they are competent to provide support to women who choose to use water, and
should keep themselves updated on the research evidence in this area.
4.
Midwives should audit
and evaluate their practice, and the outcomes of labour and birth in water, in
order to contribute to midwifery knowledge and the development of best
practice.
5.
All midwives should
ensure their record keeping of labour and births in water is accurate and
adheres to UKCC standards (UKCC, 1998b).
Policies and guidelines for the use of
water
Every
maternity unit should have, or should develop, policies and guidelines on the
use of water in labour and birth. These should be underpinned by the best
available evidence, and should be developed in consultation with supervisors
and user representatives. They should cover the following areas:
1.
Professional expertise
The
assistance of women to labour and deliver in water should be considered a core
midwifery competence. However, some will have lacked experience in this area,
and therefore appropriate education, training and supervision will be
necessary. Continuing professional development in this area should be seen as a
service requirement.
2.
Information for choice
·
All women should be offered information on the option of
using water in labour and birth. There are no grounds for seeing this option as
particularly suitable for, and acceptable to, certain groups of women on the
basis of non-clinical criteria.
·
All women who express
an interest in the use of water should be given full verbal and written
information, including where appropriate a copy of the unit’s policy. This
should include any expectations of the woman (for example, on the supply of
equipment), and what steps will be taken in the event of an emergency.
3. Criteria for use of water
Criteria
for use of water may include:
·
Women’s informed choice
·
Normal term pregnancy
at 37+ weeks
·
Singleton fetus with
cephalic presentation
·
No systemic sedation
·
Spontaneous rupture of
membranes < 24 hours
Other
non-clinical criteria – such as the availability of staff or equipment – may
reasonably be deployed; however, as with all other areas of maternal choice,
their obstruction of women’s informed decision-making should be actively kept
to a minimum.
4.
Equipment
·
Local policies should
specify essential and desirable equipment for the use of water, and make clear
who is responsible for supplying it.
·
All unit equipment
should conform to British Safety Standards, and be checked by the Health and
Safety Officer (RCM, 1998).
5.
Health and safety
·
Local infection control
policies should cover the use of water in labour and birth, and midwives should
ensure they implement universal precautions (RCM, 1998).
·
Specialist health and
safety advice should be sought to develop policies on pool cleaning.
·
Health and safety
advice on moving and handling should be adhered to at all times (RCM, 1999).
6.
Additional professional issues
·
Temperature: All
midwives should understand the physiological basis of maternal and fetal
hyperthermia, local guidelines should specify target temperatures for the water
during delivery and birth (Steer and Deans, 1995; Garland and Jones, 2000).
Maternal, core water and room temperatures should all be checked regularly.
·
Analgesia: Local
guidelines for the use of additional pain relief should be developed in
consultation with an anaesthetist, and discussed with all women prior to
labour. These should cover all forms of pain relief, including complementary
therapies.
·
Birth: Local guidelines
should be developed to guide midwives on best practice during delivery. These
should be underpinned by the best available evidence (Nikodem, 2000).
·
Emergencies: Local
guidelines should detail what steps are expected in an emergency situation. All
midwives, and all women using water for labour or birth, should know and
understand these steps.
References
Alderdice F, Renfrew M, Marchant S,
Ashurst H, Hughes P, Berridge G, Garcia J (1995) Labour and birth in water in
England and Wales: survey report. British Journal of Midwifery 3(7):
376-382
Beake S (1999) Water birth: a literature review. MIDIRS
Midwifery Digest 9(4): 473-477
Beech B (2000) Waterbirth: time to move forward. AIMS
Journal 12(2): 1-2
Garland D and Jones K (2000) Waterbirth: supporting
practice with clinical audit. MIDIRS Midwifery Digest 10(3): 333-336
House of Commons Health Committee (1992) Second
Report on the Maternity Services (Winterton report). HMSO: London
McCandlish R and Renfrew M (1993) Immersion in water
during labour and birth: the need for evaluation. Birth 20(2): 79-85
Nikodem V (2000) Immersion in water in pregnancy,
labour and birth (Cochrane Review). In: The Cochrane Library, Issue 2.
Update Software: Oxford
RCM (1998) Health and Safety Representatives’
Handbook. RCM: London
RCM (1999) Handle With Care: a midwife’s guide to
preventing back injury. RCM: London
Schorn M, McAllister J, Blanco J (1993) Water
immersion and the effect on labour. Journal of Nurse Midwifery 38(6):
336-342
Steer PJ and Deans AC (1995) Labour and birth in
water: temperature of pool is important. British Medical Journal
311(7001): 390-1
Tookey P and Gilbert R (1999) Perinatal mortality and
morbidity among babies delivered in water: surveillance study and postal
survey. British Medical Journal 319(7208): 483-487
UKCC (1992a) Scope of Professional Practice.
UKCC: London
UKCC (1992b) Code of Professional Conduct. UKCC:
London
UKCC (1998a) Midwives Rules and Code of Practice.
UKCC: London
UKCC (1998b) Guidelines for records and record
keeping. UKCC: London
Further reading
Brown L (1999) The Tide Has Turned: audit of water
birth. British Journal of Midwifery 6(4): 236-43
Burns E and Kitzinger S (2000) Midwifery
Guidelines for Use of Water in Labour. Oxford Brookes University: Oxford
Jessiman C Byers H (2000) The Highland experience:
immersion in water. British Journal of Midwifery 8(6): 357-361
Lawrence Beech BA (1996) Water Birth Unplugged:
the proceedings of the first International Water Birth Conference. Books
for Midwives Press: Cheshire
UKCC (1994) Position Statement - Waterbirth.
UKCC: London
Acknowledgements
This paper was developed with the
assistance of Dianne Garland (Practice Development Midwife, Maidstone), YP Choo
(Labour Ward Co-ordinator, Chelsea and Westminster Hospital) and Mary Coe
(Community Midwife, Southampton).
October 2000
Royal College of Midwives
Last reviewed 2005
Next review 2006