WATER IMMERSION BIRTH POLICY Water Immersion Birth BC Women’s Hospital recommends birth out of water, in the absence of evidence of benefit to the newborn. Additional care is required beyond what is routinely provided, for a woman choosing to birth in water. The woman leaves the bathtub when there is evidence of maternal or fetal compromise. The woman gives birth in a bathtub of water in agreement with her care attendants and providers. Applicability: Water immersion birth occurs in bathrubs located in Single Room Maternity Care – Cedar/ Holly of the Acute Perinatal Program. SPECIAL INSTRUCTIONS When a woman plans to give birth in water, ensure the following: Staff are confident and competent to facilitate birth in water. Waterbirth has been discussed with the woman and her support people, preferably during the antenatal period. Informed consent is obtained and documented in the patient chart. The BCWH Waterbirth Audit Tool is completed and evaluated. PROCEDURE 1.1 Inclusion Criteria Uncomplicated pregnancy, cephalic presentation and gestational age of >37 weeks In good health, fully conscious and able to get in and out of the tub In established active labour Normal vital signs Normal fetal health surveillance by intermittent auscultation Clear amniotic fluid 1.2 Exclusion Criteria Physical/ medical condition affecting mobility, or at increased risk of falling, for example: pre-pregnant BMI greater than (>) 35, paraplegia, multiple sclerosis Epidural analgesia Opioids administered within 24 hours Confirmed maternal infection with blood-born pathogen Maternal use of SSRIs Meconium stained amniotic fluid Obstetric risk factors that increase likelihood of birth complications, for example: unengaged head, uterine fibroids, history previous postpartum hemorrhage, etc. Note: Ruptured membranes and/or GBS positive cultures do not exclude a woman from labouring in water. WW.05.20 Fetal Maternal Newborn and Family Health Policy & Procedure Manual Effective Date: 10-MAY-2016 Page 1 of 4 Refer to online version – Print copy may not be current – Discard after use WATER IMMERSION BIRTH 1.2 Care for Women Giving Birth in Water The caregiver: Checks the bathtub water temperature hourly, using a floating thermometer and maintains water temperature at 35 degrees Celsius (ºC) - 37.5º C. Ensures the water is kept as clean as possible using a sieve. Maintains water levels in the tub to the level of maternal breast. Monitors the fetal heart rate in labour according to Fetal Health Surveillance Policies (Intermittent Auscultation): Monitors using a waterproof Doppler Assists the woman to leave the bathtub immediately if IA is abnormal Monitors maternal vital signs hourly: When the maternal oral temperature exceeds 37.5º C, assists the woman to leave the tub until her temperature returns to normal. The woman: Maintains adequate hydration Leaves the tub to empty her bladder at regular intervals. Leaves the tub at the advice of her care provider. 1.3 Water Immersion Birth Encourage physiologic pushing when the urge is sustained. Observe progress with a mirror; traction control is unnecessary. Avoid unnecessary touching of the head and await spontaneous restitution and birth of the body to minimize tactile stimulation of the newborn. If the fetal/newborn head is exposed to air at any time, ensure the woman remains out of the water for the birth. Once the newborn is born underwater, gently but immediately bring the newborn to the surface, place skin to skin on the mother’s chest, and cover with warm, dry blankets. Do not clamp or cut the cord under water; monitor cord length and tension to ensure it has not snapped. Should the newborn require resuscitation, clamp and cut the cord immediately and place the baby in a warm and dry environment to facilitate resuscitation. Assist the woman out of the tub and to the bed for active management (if requested) and third stage. Following birth, maintain the newborn’s temperature within the normal range. Suturing should be delayed by one hour to ensure the integrity of the repaired perineal tissue. 1.5 Safety WW.05.20 Fetal Maternal Newborn and Family Health Policy & Procedure Manual Effective Date: 10-MAY-2016 Page 2 of 4 Refer to online version – Print copy may not be current – Discard after use WATER IMMERSION BIRTH Care providers are trained in and create a plan for emergency tub evacuation for each woman using the appropriate Safe Work Procedures. The care provider or support person must remain with the woman at all times whilst she is in the bathtub. The area around the tub is kept dry and free of standing water. 1.6 Infection Control Use Routine Practices. Wear appropriate personal protective equipment to protect from anticipated contamination with body fluid/substances such as blood, amniotic fluid, urine and stool. Keep the water in the tub as clean as possible. Remove stool and debris immediately. After Use Cleaning and Disinfecting The caregiver empties the bathtub. Housekeeping staff clean and disinfect the bathtub following the usual cleaning/disinfecting procedures using Facility approved cleaners and disinfectants. DOCUMENTATION Interprofessional Progress notes Labour and Delivery Birth Summary Record Labour Partogram Physician’s History and Progress Notes BCWH Waterbirth Audit Tool REFERENCES American Academy of Pediatrics Commentary. (2005, May). Vol. 115 #5: 1413-1414. American Academy of Pediatrics Committee Opinion. (2014, April). No. 594. 1-4. Bovbjerg, M., Cheyney, M., Everson, C.(2016). Maternal and Newborn Outcomes Following Waterbirth: The Midwives Alliance of North America Statistics Project, 2004-2009 Cohort. Journal of Midwifery & Women’s Health, 61(1), p 11-20. Burns, E., Kitzinger, S. (2005). Midwifery Guidelines for the Use of Water in Labour (2nd Ed.) Pg 7 – 9, Oxford Brookes University, School of Health and Social Care. Cluett, ER; Nikidem, VC; McCandlish, RE; Burns, EE: (2006). Immersion in Water In pregnancy, labour and birth. Cochrane Database of Systematic Reviews 1. College of Midwives of British Columbia. CMBC (2002, February). Guideline for the Use of Water in Labour and Birth. Clinical Practice Guideline. Department of Midwifery. Guidelines to Practice, Water for Labour and Birth (2012). Children’s & Women’s Health Centre of British Columbia and Providence Healthcare (SPH). Vancouver. Eckert, K., Turnbull, D., MacLennan, A., (2001). Immersion in water of the first stage of labour; a randomized control trial. Birth, 28(2) p 84-93. Group B Streptococcal Guidelines Recommendations for Prevention of Neonatal GBS. Vancouver: C&W. WW.05.20 Fetal Maternal Newborn and Family Health Policy & Procedure Manual Effective Date: 10-MAY-2016 Page 3 of 4 Refer to online version – Print copy may not be current – Discard after use WATER IMMERSION BIRTH Government of Western Australia (2009). WA Labour & Birth in Water Clinical Guidelines. Infection Control Manual (2000). Standard Precautions. Vancouver: C&W Intermittent Fetal Heart Auscultation Johnson, P. (1996). Birth underwater: To breathe or not to breathe. British Journal of Obstetrics and Gynecology, 103, 202-208. Lowdermilk, D., Perry, S. and Bobak, I. (2000). Maternity and Women’s Health Care. (7th ed.) pg. 549. St. Louis: Mosby - Year Book. Nutter, E., Meyer, S., Shaw, J., et al (2014). Waterbirth: An Integrative Analysis of Peer-Reviewed Literature. 59(3). 286-319. Pinette, M., Wax, J., Wilson, E. (2004). Risk of underwater birth. American Journal of Obstetricians and Gynecologists. 190: 1211-1215. Royal College of Obstetricians and Gynaecologists and Royal College of Midwives Joint Statement No.1 (2006, April). Professor Z Alfirevic FRCOG, Liverpool and Ms D Gould, RM. Rush, J., Burlock, S., Lambert, K., Looseley-Millman, M., Hutchison, B., & Enkin, M. (1996). The effects of whirlpool baths in labour: A randomized, controlled trial. Birth, 23 (3), 136-143. Zanett-Dallenback, R; Lapaire,O; Maertens, A; Frei,R; Holzgreve, W; Hosli, I. (2006). Water Birth: is the water an additional reservoir for group B streptococcus? Arch Gynecol Obstet 273: 236-238. WW.05.20 Fetal Maternal Newborn and Family Health Policy & Procedure Manual Effective Date: 10-MAY-2016 Page 4 of 4 Refer to online version – Print copy may not be current – Discard after use .