SDMS ID: P2010/0492-001 2.

18-08WACS Title: Replaces: Description: Target Audience: Key Words: Policy Supported: Immersion in Water during Labour and/or Birth QVMU Water Birth Policy Use of water in labour and/or birth Midwives and medical officers, QVMU Water birth P2010/0484-001 Care of Normal (Low Risk) Women in Labour

Purpose: A womans request to labour and/or birth in water will be supported if she is considered low risk and the midwife is confident and competent to assist. Private patients may labour and/or birth in water following consultation with their obstetrician. If the midwife does not feel comfortable facilitating a water birth, it is their responsibility to inform the woman and attempt to find a midwife to take over her care. If this is not possible, then the woman should be advised that with her and her babys safety in mind she should leave the bath for the birth of her baby. A woman is excluded from using the bath for birth in the presence of any of the following: <37 weeks gestation Multiple pregnancy Pre-eclampsia or hypertension Previous post-partum haemorrhage Insulin dependent diabetes Active herpes Known HIV positive Alcohol or drug abuse Mobility/skeletal problems that may prevent leaving the bath when necessary Any presentation other than cephalic Intrauterine growth restriction Previous or current risk factors for shoulder dystocia Meconium stained liquor Febrile or evidence of maternal infection (maternal temperature > 37.6C) Fetal heart rate abnormalities Intrapartum haemorrhage Maternal narcotic use within the last 4 hours Epidural analgesia Rupture membranes >24 hours First Stage of Labour Maternal and fetal wellbeing are monitored as per the Care of Normal (Low Risk) Women in Labour WACSClinproc2.1 The woman should be in active labour prior to entering the bath.
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The bath should be filled to the level of the womans breasts when she is sitting in the bath. Ensure that a midwife or support person is in the room at all times that the woman is in the bath. Women should be encouraged to regulate the temperature of the water to their own comfort during the first stage of labour. Encourage oral fluids to prevent dehydration. Nitrous oxide and oxygen may be used in the bath if required. Management of Unplanned Water Birth Women who use the bath for pain relief in first stage should be asked to leave the water prior to the onset of second stage. If the woman refuses or is unable to leave the water and birth is imminent, it may not be safe to drain the water from the bath. The baby must be born completely underwater, with no air contact until he/she is brought gently to the surface immediately after the body is born. It may be appropriate to ask the woman to stand up to birth her baby into air. If the woman raises herself out of the water and exposes the fetal scalp/head to air she should be advised to remain out of the water to avoid the risk of premature gasping underwater. Second Stage Ensure the water temperature is between 35 to 37C Maternal and fetal wellbeing are monitored as per the Care of Normal (Low Risk) Women in Labour WACSClinproc2.1 To minimised stimulation of the baby underwater a hands off approach , supported by verbal guidance is recommended. It is not necessary to control the head or feel for the presence of nuchal cord. The cord can be loosened and disentangled as the baby is born. Assist with the birth of the shoulders if required. Avoid undue traction on the umbilical cord. The cord is not to be clamped and cut underwater. Clamping or cutting the umbilical cord stimulates the baby to breathe. If the cord is tightly around the neck the mother can stand so the cord can be clamped and cut. The birth must then continue with the mother standing. The baby must be born completely underwater, with no air contact until he/she is brought gently to the surface immediately after the body is delivered. Ensure the babys head remains above the surface of the water. Maintain skin to skin contact with the mother. Dry babys exposed head an d skin to reduce heat loss. Third Stage Active management of third stage is recommended for all women as per the Care of Normal (Low Risk) Women in Labour WACSClinProc2.1. Intramuscular injections should not be administered underwater. Birth of the placenta underwater is not recommended due to the theoretical risk of water embolism. The bath should be drained or the mother requested to leave the bath to birth the placenta. Documentation Accurate contemporaneous records should be kept as per Care of the Normal (Low Risk) Women in Labour WACSClinProc2.1 The times of entering and leaving the bath should be clearly documented, including the reason for leaving the bath.
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It is important that it is recorded clearly whether the baby was born under water. Cleaning The bath and all other equipment should be thoroughly cleaned and dried after used in accordance with infection control guidelines.

Attachments
Attachment 1 References

Performance Indicators: Evaluation of compliance with guideline to be achieved through medical record audit annually by clinical Quality improvement Midwife WACS Review Date: Annually verified for currency or as changes occur, and reviewed every 3 years via Policy and Procedure working group coordinated by the Clinical and Quality improvement midwife. November 2009 Midwives and medical staff WACS Dr A Dennis Co-Director (Medical) Sue McBeath Co-Director (Nursing & Midwifery) Womens & Childrens Services

Stakeholders: Developed by:

Dr A Dennis Co-Director (Medical) Womens & Childrens Services

Sue McBeath Co-Director (Nursing & Midwifery) Womens & Childrens Services

Date: _________________________

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ATTACHMENT 1 REFERENCES Anderson, T 2004 Time to throw the waterbirth thermometer away? MIDIRS Midwifery Digest, vol. 14, no.3, pp.370-374. Australian College of Midwives Position Statement 2005 The use of water during labour and birth online: http://www.midwives.org.au/AboutUs/ACMPositionStatements/TheUseofWaterDuringLabo urandBirth/tabid/266/Default.aspx Burns, E & Kitzinger, S 2005 Midwifery Guidelines for the Use of Water in Labour, Oxford Brookes University Cluett, E, Nikodem, V, McCandish, R & Burn, E 2002 Immersion in water in pregnancy, labour and birth Cochrane Database of Systematic Reviews, Issue 2. Art. No.: CD000111.DOI: 10.1002/14651858.CD000111.pub2. Joanna Briggs Institute 2007 Labour: non pharmacological pain relief online: http://www.joannabriggs.edu.au/cis/gu_manual_index.php?MID=962 King Edward Memorial Hospital Clinical Guidelines 2002 Unexpected underwater birth online: http://www.kemh.health.wa.gov.au/development/manuals/sectionb/index.htm New Zealand College of Midwives Consensus Statement 2002 The use of water in labour and birth online: http://www.midwife.org.nz/index.cfm/1,108,html Plumb, J, Holwell, D, Burton, R & Steer, P 2007 Water birth for women with GBS: a pip e dream? Practising Midwife, vol. 10, no. 4, pp. 25-28. Royal College of Obstetricians and Gynaecologist/Royal College of Midwives Joint Statement No. 1 2006 Immersion in water during labour and birth online: http://www.rcog.org.uk/index.asp?PageID=546 Royal Womens Hospital Clinical Practise Guidelines 2006 Water immersion: first stage of labour: care of women online: http://www.thewomens.org.au/WaterImmersionFirstStageofLabourCareofWomen South Australian Department of Health 2005 Policy Birth in Water online: http://www.health.sa.gov.au/Default.aspx?tabid=62 Zanetti-Dallenbach, R, Lapaire, O, Maertens, A, Frei, R, Holzgreve, W & Hosli I 2005 Water birth: is the water an additional reservoir for group B streptococcus? Arch Gynecol Obstet Vol. 273, pp.236-238.

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