[CG] Waterbirth care of a woman labouring at home or in hospital

Action

Rationale

One-to-one midwifery care when in pool

Safety of mother and baby (NICE 2007)

Room should be warm but well ventilated

To maintain temperature of water and prevent neonatal hypothermia

Timing of entry into the pool is the woman’s choice

Document time of entry into the pool

Some evidence would suggest that contractions may become less frequent if prolonged immersion, however, other sources suggest that the pool can be beneficial for women undergoing a prolonged latent phase.

NMC standards 

Ensure water is deep enough to cover abdomen 

Provides enough hydrostatic pressure to provide adequate support for the pregnant woman (Garland, 1997)

Temperature of water must be no greater than 37.5c – then recorded hourly and after each topping up of the pool.

To reduce the risk of maternal pyrexia leading to increased peripheral perfusion, resulting in fetal compromise.

To ensure maintenance of desired temperatures.

Check maternal temperature 2 hourly.

Women with temp > 37c should be removed from the pool immediately

Prevention of maternal/fetal hyperthermia

(Charles, 1998)

Ensure that both woman and birth

attendants are adequately hydrated

To maintain hydration in a humid environment

As per KCND pathways for 1^st and 2^nd stage in labour

To monitor fetal well-being (Midirs,2005)

Flotation aids should be made available

For comfort and to aid optimal positioning

When approaching point of birth, water  temperature should be 36c – 37.5c.

Cooler water stimulates the initiation of baby’s breathing reflex 

Maternal faeces and blood clots/show must be removed from the pool with a sieve.

Prevention of maternal/neonatal infection

(Kingsley et al, 1999)

On evidence of meconium stained liquor, woman should be asked to exit the pool

Meconium stained liquor may be a sign of fetal compromise, which may lead to gasping under water

Pushing should be non-directed and physiological. Length of second stage should be in line with local and national guidelines.

Non-directed pushing is less likely to lead to exhaustion in mother and fetal distress in baby. It reduces the risk of perineal tearing and need for episiotomy

The baby should be born fully submerged and be brought to the surface head first, gently and without delay.

Once out of the water, the baby’s head should never be re-immersed. 

Prevents the initiation of breathing underwater (Johnston, 1996)

Never feel for nuchal cord.

Never clamp and cut the cord under water

Could trigger respiration in the baby

Check umbilical cord has not snapped underwater – some cords are very short

Prevention of exsanguination of the Baby (Crow and Preston, 2002)

Assess apgars one minute after the baby surfaces from the water. Be aware that baby can stay blue for a few seconds longer than a land birth.

Assess as per resuscitation guidelines and initiate resuscitation as required

Initiation of breathing is slower and babies born in water often don’t cry immediately. They continue to receive oxygen from the placenta as the cord takes longer to spasm due to the warm water

Third Stage of Labour

As per birth plan.

Oxytocic drugs should not be given in the pool. Regardless of choice of third stage management, the cord should not be cut until it has stopped pulsating (unless resuscitation is required)

A physiological third stage may take place in or out of the pool

If the midwife has any concerns, the woman should be asked to leave the pool e.g heavy blood loss, feels faint, retained placenta

Informed choice

Safer environment for resuscitation

Clear contemporaneous records must be maintained

An accurate and contemporaneous record is essential