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Author: Dianne Garland FRCM SRN RM ADM PGCEA MSc Freelance midwife
During these changing and challenging times I have spent the last few months sharing information about the use of water for labour and birth. I have written widely, undertaken interviews and started Zoom sessions to provide colleagues with up to date and robust information.
I wish to share this information in a blog which provides some background, latest information and ways to support the use of water during these times.
Availability of pools in the UK and worldwide.
In many settings in both the UK and abroad, one of the biggest changes has been a postponement of home birth, waterbirths and even birth centres. While I am writing this blog there appears to be a relaxation on all three settings, the overall picture was based on availability of staff and ambulances. With regard to waterbirths Barbara Harper in her Waterbirth International paper (March 2020) wrote the “feeling of theoretical risk or presumption of fear” has led to many stopping the use of water for labour and birth.
This dynamic situation is still developing and some fears remain, however, as more scientific, clinical and practical evidence is published the use of birthing pools has started to resume.
I believe there is universal agreement that if the mother (although household members are not mentioned) who show symptoms, would be excluded from using a birthing pool. The main reason that I am aware of is that symptoms can deteriorate rapidly, mother and baby would require extra monitoring and require a hospital labour ward environment.
Two main issues arise from the COVID 19 scenario, firstly the PPE required to protect mother, baby, birth companion and staff, secondly, a new development is the “sticky blood” thromboembolic condition. A group of Professors and doctors working with patients who have COVID 19 have been discussing “baffling” observations from the frontline, including this severe illness. This thromboembolic condition seems to be when patients have severe symptoms, and does not appear to relate to inadequate hydration. I believe we should continue to follow standard guidelines and ongoing teaching (via Zoom at present!) that women should aim to drink minimum 500mls isotonic drinks every hour, to reduce dehydration when in a birthing pool.
In 2018 the CQC (Care Quality Commission) stated that 20% women use water during labour of which 10% (half) stay in and birth. It will be interesting to see if figures increase or decrease during this time. BPIAB and personal correspondence form colleagues seem to suggest that pool purchase has increased by as much as 25% compared to this time last year. There may be several reasons for this increase. Firstly, if pool rooms in labour ward have been redeployed and some birth centres closed, mothers have chosen to use their own pool to ensure access.
Secondly, COVID 19 is a droplet infection. With the best evidence we have at present it is not waterborne and thus does not appear to add any extra risk to mothers, babies, birth companions or midwives. Water in the UK and USA is chlorinated and this already aims to kill any virus in our tap water (Harper 2020). There may be Covid virus particles in faeces, however, only one study has managed to culture COVID19 from faeces. If fecal matter contaminates the water it should be removed, and if unable to clear the material, the mother should be encouraged to leave the water whilst it is emptied, cleaned (in line with manufacturers instructions) then refilled. For asymptomatic mothers this is not a reason to decline use of a pool.
Finally, data which should be collected with regard to service changes (postponed home/waterbirths, problems with staffing or ambulance services) it is important to capture mothers’ and midwives' stories. The number of waterbirths may have altered (most midwives reporting an increase) and can be compared to the same time last year, to see the impact COVID 19 has had on the use of water.
Worldwide the picture is very mixed, some hospitals and birth centres have continued with their waterbirth services. In personal correspondence some units have seen a decrease due to perceived fear of infection of mothers and babies. This was one reason to commence ZOOM online sessions and to date have hosted over 100 colleagues from 12 different countries.
At home in labour or birth, many women already use showers or their own baths which can provide some physical, psychological and hormonal benefits for women.
On a positive note a shower can be directed to any muscle, ligament or any part of a woman’s body during early labour. Warm water will relax her and add a new dimension to supportive pain relief. A bath increases buoyancy for the mother and depending on the size of her bath may provide increased mobility and position change. However, a home birthing pool e.g. the pools available from Birth Pool in a Box, allow free movement, change of position and deep relaxation by purchasing a birthing pool with a single use liner, a mother creates her own environment.
The benefits of using water have been well document since the mid 1980’s with the most recent article from New Zealand (Maude and Kim 20/5/20) continue to identify “water immersion for labour and birth is a positive intervention that benefits women with uncomplicated pregnancies”
During this pandemic of COVID 19 the issue of availability of pools is almost universally agreed that they can safely be offered to non symptomatic women, with robust PPE and some changes to standard care. During my Zoom sessions I highlight several issues which may have an impact on women’s care in pools. Monitoring of the fetal heart can be safely achieved without the midwife placing her hands in the water, why cannot the mother or her birth companion hold the Doppler on her abdomen.
Secondly, maintaining a well ventilated room assists the mother in not overheating, during this time it is not recommended the use of fans to circulate air. If possible open a window or door, providing privacy by using a screen across the door.
Thirdly, one concern is wearing appropriate PPE during water labour/birth, differences do exist in different care settings but my professional opinion is that midwives should work within safe parameters, employer guidelines and use their professional opinion regarding PPE. If the midwife believes they require different PPE, it should be discussed with parents and employers.
Several professional statements have been issued from Waterbirth international, Royal College of Midwives and Oxford Brookes University. I have not become aware of any other countries who have yet published information for midwives. Some of the messages from these organisations have been mixed, how to safely auscultate the fetal heart, access to appropriate PPE to name two. Professionally I believe that the Oxford Brookes university paper provides the most robust multi-professional guidance at this time.
Finally, as a professional I believe that we need to collect data on clinical outcomes for mother and baby, increase or decrease in pool usage and improved breastfeeding rates. Information (Qualitative) data of how midwives and families have been supporting the use of water during COVID 19 pandemic.
Advice from Birth Pool in a Box
Existing cleaning, decontamination and set up procedures have not altered in light of covid. It should be stressed that the unique fitted single use liners provided by Birth Pool in a Box are not for use more than once.
Final thoughts from Renfrew et al 2020.
“ Practice environments have changed almost beyond recognition, especially in hospitals, and a heightened sense of urgency and even fear can, understandably, predominate. The public health and medical imperative is such that there is a
perception that the needs, preferences and decisions of childbearing women and even their rights and those of their babies are less important or even irrelevant ( Birthrights, 2020 ). At such a time of rapidly changing priorities and heightened awareness of risk, and despite the overwhelming sense of crisis, a focus on evidence is essential to inform decision-making and to avoid harm. Making swift, if well intentioned, changes without evidence of effectiveness may lead to unanticipated consequences which could seriously compromise the quality of care and outcomes.”
This seems a great way to finish this blog so my thanks go not just to the team who wrote this paper, but as a waterbirth expert to all midwives and other maternity carers who continue to offer a water labour/birth service.
Zoom sessions details available Dianne@midwifeexpert.com
Harper,B 23/3/20 Keeping waterbirth safe during Covid 19. USA
Maude,RM and Kim,M .2020 Getting into the water: a prospective observational study of water immersion for labour and birth at a New Zealand district health board.BMC Pregnancy and Childbirth Vol. 20 No. 312
Oxford Brookes University.29/4/20 Coronavirus Covid 19 – supporting healthy pregnant women to safely give birth.Oxford UK
RCM 2020 Clinical briefing;Waterbirth- COVID 19 24/4 and 7/5
Renfrew ,MJ. et al 2020 Sustaining quality midwifery care in a pandemic and beyond Midwifery 88 102759