A Study of Waterbirth Standards.

This study looks at a three year period (1994-1996) at one hospital, Good Hope NHS Trust, Birmingham, England, where a portable pool had been donated to the hospital by a client, then a permanent bath was installed. During that three-year period 1,082 women stated prenatally that they wished to use a pool during labor. Of them, 541 actually entered the pool and 343 delivered in it, including 10 VBAC births.

Some of the guidelines for use of the pool at Good Hope include:

* The use of tap water with nothing added

* Maintenance of the water temperature at 37 [degrees] C for the birth

* A sample of the water prior to entry is taken

* A high vaginal swab following the delivery of the placenta is obtained

* Ear and umbilical swabs from the baby are taken

* The use of long gloves by the midwives and nurses who have direct contact with the patient in the water

The three main reasons that women left the pool included:

* Concerns by staff about fetal well being (fetal heart rates, meconium, malpresentation)

* Requests for further analgesia (consistently primigravidas)

* Slow progress

Twice as many primigravida left the pool prior to delivery and more multigravida delivered in the pool (57 percent) compared to primips (43 percent). It was noted that primips usually requested to leave the pool during transition and that after the midwives caught on to this, they encouraged these women to stay where they were and helped them cope through the confusion of transition.

Eighty-seven percent of women who entered the pool had spontaneous onset of labor. The remaining 13 percent had vaginal prostin inserted for post-maturity. Sixty-eight percent of the induced labors delivered in the pool.

The experience gathered in this large study suggests the following guidelines on when to enter the bath:

* Primigravida dilation should be 3-4 cm

* Multigravida dilation should be 4-5 cm

If the woman enters the pool when the cervix is between 1-2 cm, labor may stop or slow down. That is not a reason to restrict a woman from the bath. If a labor does slow down or stop, then she may leave the pool and re-enter once labor becomes established.

Apgar scores of 7 or greater were reported in 94 percent of the babies at one minute and 99.7 percent at five minutes. There was one neonatal death reported in the bath group. The cause was attributed to intracranial hemorrhage.

There were no known infections of the cord and only one maternal infection postpartum, which responded to antibiotics.

Of the women, 46 percent had an intact perineum, 15 percent experienced first-degree tears and 24 percent experienced second-degree tears. The numbers were further sorted into primigravida and multigravidas with primigravidas experiencing less tearing on the average.

Amniotomy is not performed routinely. There was no difference experienced in cases with or without ruptured membranes. It is sometimes difficult to assess when membranes rupture in the water. Vaginal examinations are safe and are performed routinely while women are in the pool. There is no evidence of increased risk of infection in mothers who labor in water or babies who are born in water.

The most common delivery position is a supported squat, with the mother being supported by the husband or partner.

There is never any attempt to feel for a tight nuchal cord or to clamp or cut if a tight cord is noticed. The body is delivered, then the cord is unraveled while the baby is still under the water.

Waterbabies tend to take a few seconds longer to cry than "land" babies. This is now expected and normal.

Key points:

* Data from the audit suggests that labor and birth in water is no more dangerous for low risk women than land birth.

* Women using the pool like it and feel in control of their labors and find it a rewarding experience.

* Evaluation in combination with comments from women and the observations and experiences of midwives are important to identifying safe and effective waterbirth practices.

* Consideration from previous research studies is essential.

The Waterbirth Research Binder is a compilation of published articles [no media, only journals] and is available from Global Maternal/Child Health Association for $42 postage paid. Individual articles are always available for $3 each, either faxed or mailed. Many nurse managers and midwives use these articles for quick reference and for education.

--From Brown, Lyn. "The tide has turned: Audit of water birth." British Journal of Midwifery, April 1998, Vol. 6., No. 4 pp 236-243 and Reprinted from Midwifery Today E-News 1:45, Nov. 5, 1999). To subscribe to the E-News write: [e-mail]. For all other matters contact Midwifery Today, PO Box 2672-940, Eugene OR 97402; 541-344-7438, [e-mail], http://www.midwiferytoday.com