Disposable Birth Pool Plugs? No!

Last week we had a request to supply a box of single-use, disposable birth pool plugs for a hospital birth pool.   We were surprised to hear that any Trusts were using conventional bath plugs in their birth pools. Here’s why. 

Cleaning a bath plug and chain

Birth pool plugs are not permitted to have chains on them (HTM64 Health Technical Memorandum). This is because you can’t attach the other end of the chain to anything because of the cleaning challenges, and the chain itself is also just another crevice where bacteria may breed. In theory, the plug chains are also a ligature risk.

Access to the birth pool plug by midwives

After I bath my children, I ask them to pull the plug out as I’m not keen on dirty bath suds up to my elbow! A hospital birth pool is MUCH deeper than even my children insist on. Leaning in to pull out the plug, probably right up to the midwife’s shoulder, through water which is likely to be contaminated with faeces and blood, isn’t ideal. While the midwife has already had their hands in the water, it’s not the same as trying to reach all the way down and not contaminate their uniform sleeves. Some Trusts have proposed providing the midwives with gauntlet gloves, but then there is the rigmarole of cleaning them, finding them, having pairs that fit everyone’s arm length… Far better to avoid the situation at all and not have disposable birth pool plugs!

Finding the plugs!

We still travel with a travellers’ emergency bath plug as many’s the time that we’ve ended up in a hotel or holiday home with no bath plug in sight. Imagine the challenge of trying to track plugs through the cleaning process and back again! So the obvious answer appears to be the disposable birth pool plugs that we at Aquabirths were asked to supply, but who will keep an eye on how many are left and when they need to be re-ordered? And of course, with a disposable item, there is always the…

Eco considerations

Every Little Counts and all that, and everything we can do to try to reduce the impact on our environment makes an impact. If we can move away from disposable items. Generally, disposable items in the NHS are incinerated, with serious ecological impacts. Disposable birth pool plugs are not necessary. There’s a much better solution…

Aquabirths’ Birth Pool Plug Solution!

Aquabirths do not supply hospital birth pools with disposable plugs. Our birth pools come with built in grated wastes and an integrated valve to stop water flowing out, or to release it after the birth. To “plug” or “unplug” the birth pool the midwife simply needs to open the valve!

Active labour and birth in Obstetric Units

Hi-Lo active birth chair

The benefits of upright and active labour and birth to women, babies and a healthy labour are uncontroversial and well established – and yet women are still so often confined to the bed in obstetric units.

Women who are welcomed into a midwife led unit, on the other hand, tend to have rooms where the bed is not centre stage, and instead the standard birth support equipment lends itself to upright, kneeling, squatting or forward leaning positions for labour and birth. Access to a birth pool is common, as are slings, birth couches, mats and balls.

Walk into most obstetric units and the untrained eye would have a hard time recognising it from any other hospital room. Machines, cables, bleeps and flashing lights and of course, in the centre, the bed. We spend 1/3 of our lives lying down in bed. When we are admitted to hospital for any other reason than to give birth, we lie down in bed. There is every psychological reason to automatically go to the bed and lie down when we’re admitted in labour – and every physiological reason not to!

By taking away the focus of the room from the bed and towards ways to support active labour and birth we know that we can shorten labours, help with babies’ positioning, reduce the need for pain relief and have more positive births. It is therefore not only a real worry that women who are birthing in the obstetric unit so often don’t have the automatic access to the low cost, high value equipment which supports this, it actively causes harm by reducing and limiting the woman’s ability to move in labour.

We call upon the commissioners and managers of obstetric units to consider the ways that their birth units can have the best of both worlds – the low-tech, high impact equipment which helps women to remain active, and the high-tech, high impact equipment available if necessary, but ideally easily accessible but slightly hidden, eg behind a screen. While, clearly, hospital birth pools can’t be plumbed into every obstetric unit room, there’s no reason why each room can’t benefit from a HiLo Birth Chair, or something similar. This simple piece of equipment is perfect for supporting active birth in every room in the obstetric unit. Fast and easy to clean, small footprint for even the smallest obstetric room, the HiLo Birth Chair provides excellent support for multiple labour and birth positions including upright breech birth. It supports normal human birth physiology and biomechanics while permitting extremely easy access to the woman in order to offer monitoring of all kinds, and all other tests and checks which can be performed without the woman lying down (ie almost everything). The reduction in the use of anaesthesia, caesareans and other expensive interventions1 that are likely to come from using the HiLo Birth Chair in each obstetric room will mean that it will quickly pay for itself. Indeed, just one avoided caesarean covers its cost as well as stopping that woman from possible life-long complications from major surgery.

We need to move away from an either/or situation for women. It shouldn’t be that only women on the MLU can access evidence based equipment that can reduce costs for the Trust, reduce interventions for the mother and baby and increase the chance of each mother having a positive birth. Obstetric units can benefit from this equipment too – saving money and having better outcomes for women and babies.

Reference

  1. Cochrane Review, “Mothers position during the first stage of labour” https://www.cochrane.org/CD003934/PREG_mothers-position-during-the-first-stage-of-labour

 

Waterbirth, GBS and Hospital Birth Pools

Can women who are found to be carrying Group B Strep (GBS) still have a waterbirth (in a hospital birth pool or at a home water birth)? Yes!

Hospital birth pool GBS is very common. It’s thought that around 1 in 4 women carry the bacteria in their vagina, but despite this very few babies become affected by it. However those who are affected can become extremely ill, and tragically some will die. Because of this, prophylactic antibiotics given during labour are offered to women who are found to be carrying GBS, which does reduce the number of affected babies.

Our binary maternity labelling (low/high risk) means that any woman with any additional issue in their pregnancy becomes “high risk”, and many trusts’ guidance on waterbirth states that only “low risk” women may use the birth pool. In many cases this leads to women who would hugely benefit from a birth pool, and who would be far more likely to have a straightforward, drug-free birth by using one, being denied access to them.

Is this reasonable, or should women be supported to have a waterbirth if they wish, if they’re a GBS carrier?

What is the evidence?
Cohain1 states that out of 4432 waterbirths, only one incident of GBS was reported, whereas the rate for dry land births was one in 1450. This implies that waterbirth may significantly lower the rates of GBS infection in babies who are born in a birth pool. Research by Zanetti-Dällenbach R2 et al found that even though the levels of GBS in the birth pool were higher when babies were born into the water compared to labouring in water and birthing on land, the levels of GBS infection in the babies born in water was lower. While no large scale RCTs have yet been done, this data does show that birthing in water may in fact be a hugely important way to reduce the numbers of babies who are contracting GBS after birth and perhaps we should be encouraging women to birth in water as a way to reduce the infection rate! Even the Royal College of Obstetrics and Gynaecology (RCOG) states that waterbirth is not contraindicated for women who are carrying GBS3.

Women who are found to be carrying GBS before labour are offered prophylactic antibiotics which, if she chooses to accept them, will be given via a cannula during birth. This is often considered to be a contraindication for labouring and birthing in water, but in fact it is very simply to protect the cannula during a waterbirth. Women can either keep their hand out of the water, or if they feel they might want to put their hand into the birth pool, the midwife can place a close fitting plastic glove over her hand and seal it with an appropriate skin-safe waterproof tape.

In conclusion, the evidence we have – limited as it is – shows that giving birth in water is actually protective against the baby contracting GBS, and as such we shouldn’t be asking whether women should be supported to birth in water if they are carrying GBS. Instead we should be asking why are they so often told that they must birth on dry land?

Further reading:

AIMS: Group B Strep Explained by Sara Wickham https://www.aims.org.uk/shop/item/group-b-strep-explained

References:

1)  Cohain, JS, Midwifery Today, “Waterbirth and GBS”: https://www.ncbi.nlm.nih.gov/pubmed/21322437

2)  Zanetti-Dällenbach R, “Water birth: is the water an additional reservoir for group B streptococcus?“ https://www.ncbi.nlm.nih.gov/pubmed/16208480

3) RCOG on GBS and waterbirth: https://obgyn.onlinelibrary.wiley.com/doi/full/10.1111/1471-0528.14821 (point 7.5)

Topic Summary: Hospital birth pools and GBS: what is the evidence and what is best practise?

High BMI & Guidelines for Hospital Birth Pools

water birth in birth pool, woman with high bmiHow can Trusts ensure that their guidelines for hospital birth pools support women with a high BMI?

The benefits of using a birth pool for labour and birth are well documented, and yet there is a group of women who are regularly denied the chance to use this powerful form of pain relief and comfort when giving birth to their babies: women with a high BMI.

The most common reason given by Trusts for the denial of access to a birth pool for women with a high BMI is that if she were to collapse, she’d be harder to get out of the pool. Another reason is that women of high BMI might be less flexible, and less able to step out of the pool themselves. A recent article by AIMS clearly debunks both of these considerations. (See here: https://www.aims.org.uk/journal/item/waterbirth-high-bmi)

But what if women with a high BMI collapse in the birth pool?
The term “BMI” does not mean “weight”. A short women who is overweight might weigh less than a tall, slim woman, and yet the short woman may be classed as “high BMI”, and the tall woman “normal BMI”. The heavier woman would be permitted access to the hospital birth pool, whereas the shorter, lighter woman might not. This is clearly illogical as the taller woman would be heavier, and harder to lift out of the pool, despite her lower BMI.

Any woman may need to be lifted out of the birth pool, irrespective of her weight or BMI, and so appropriate equipment and guidelines should be available at all times for every person using the pool.  This should not need to be weight limited. For instance, slings which support people of all weights are commonly available through hospital suppliers.

Methods to help women out of the blow-up birth pools used at home which do NOT include slashing the pool are well known. Slashing the pool will flood the floor, and nearby electrical items, with water, and the women will “flow” out with the water in an uncontrolled way. Instead, supporting the woman to remain above the water (birth partners are always going to help with this!) while a managed removal happens is much safer. A fast deflation of the centre ring will lower the sides while containing the water and retaining the structure of the birth pool.

Women with a high BMI and mobility issues
Another reason commonly given to deny women with a high BMI access to a hospital birth pool is that these women may be less likely to be able to leave the pool without assistance. In other words, the assumption is made that larger women will have reduced mobility. Any woman may have mobility issues, so this should be a separate consideration, no matter her BMI. That said, women who may find moving on land harder, for any reason, may find that the supportive effect of water in a birth pool can help them to remain more mobile in labour, thus leading to a higher chance of a positive, straightforward birth. It therefore makes sense to do what we can to support women to access the water, even if they are limited in their ability to jump out of the pool themselves – and this has nothing to do with BMI.

There are many different considerations for Trusts when they are writing their guidelines for women who wish to labour and/or birth in water. Using BMI as a barrier to access, however, needs urgent reconsideration, in order to ensure that all women are given the opportunity to birth in the way that is right for them – and which has many benefits for the Trust as well, as a low-cost way to support normal birth and better birth outcomes.

For a full and detailed report on the issue of access to a birth pool and BMI, please read the AIMS Journal article here: https://www.aims.org.uk/journal/item/waterbirth-high-bmi

 

Waterbirth following a previous Caesarean Birth – YES You Can!

Aquabirths was delighted to read this lovely birth story by Jo, published by doula Cathy Williams. Jo had her first baby by caesarean when she found that her baby was breech when she went into hospital in labour, and she was told by hospital staff that she had no other option (which isn’t true!).

For Jo’s second baby, she was very interested to find that her consultant was very supportive of a VBAC – a vaginal birth after previous caesarean birth(s). Jo had previously thought that she would not be able to have a vaginal birth, having had her first baby by caesarean. In fact, VBAC is very often the safest option for women who would prefer a vaginal birth.

After extensive research, Jo decided that she would like to birth in a birth pool on the midwife led unit, and this is exactly what happened. Thanks to the support of her doula, Cathy, Jo’s research and strong self advocacy, and as Jo herself puts it, “some balls”, Jo birthed her baby how she wanted, in a birth pool, with only the interventions that she was happy to accept.

Congratulations from all of us at Aquabirths, Jo, and thank you to Cathy Williams for sharing Jo’s story!

For more information on VBAC (Vaginal Birth After Caesarean), see the AIMS book “Birth After Caesarean

Supporting Plus Size Women – a Must-Read Guide for Midwives

This is a lovely article with some very helpful information for midwives and other carers of pregnant women who are plus size. It’s so important to remember that larger women are not necessarily less healthy than slimmer women- and even if they do have medical conditions related to their weight, they still need and deserve personalised care.

And of course, labour and birth in water offers huge benefits to women of all sizes, and women should not be denied access to water just because they are “plus size”.

Read the full article here…

OASi – The Right Care for Serious Tears?

The OASI Bundle refers to a specified list (the Bundle) of interventions which are being evaluated to see whether they reduce the numbers of very serious tears during birth, known as OASI, which affect the woman’s anal sphincter. The package is outlined by RCOG here. These types of tears can be hard to repair, and can lead to life changing injuries for women. While Aquabirths absolutely supports the concept of trying to reduce the chances of these types of birth injuries, there are some serious concerns about the OASI Bundle and whether it is the best way to achieve this.

OASI stands for “Obstetric Anal Sphincter Injury”. The Bundle contains four components:

  • Communication with women about their chance of OASI (more about this in a moment)
  • Using the “Finnish Grip” as the baby is born
  • Use of episiotomy as per indications in the details of the Bundle
  • Checking the mother by inserting a finger into her rectum and feeling for tears which might not be immediately obvious and which can be present even if her perineum is intact.

We were initially pleasantly surprised to see a list which specifically included the requirement to speak to women about the intervention. While sometimes a guideline will say “do X with consent”, rather than just “do X”, it is very exciting to see a specific component of a Bundle being that women should be making an informed decision to be a part of a trial. However – despite being the first part of the Bundle (after all, nothing can be done without consent) the fact that this component is listed last in RCOG’s detailed guidelines speaks volumes about the consideration of its importance. Even more worryingly, in practice, midwives are reporting that women are arriving at hospital in labour without having been given information about the Bundle by their community midwife and therefore ensuring that ensuring that informed consent is given is much harder. This should itself invalidate the data that is being collected by the trial, according to its own rules, and performing any intervention on women without informed consent is, in law, common assault.

The Finnish Grip is the main intervention in OASI. It involves gripping the perineum with the intention of redirecting pressure towards other vaginal and labial tissues. This video shows it in practice (keep the sound off – the artificial sound effects are somewhat irritating, especially the “push-push-push”!) You will note from the video that the “woman” is on her back, pushing against gravity with her baby’s head therefore pressing down hard against the perineum. The Finnish Grip is designed to push the baby’s head up and away from the perineum – yet encouraging women to be upright or forward facing has the same effect! With an upright, forward facing or even side lying position the baby’s head is lifted by gravity towards the woman’s front, rather than being dropped by gravity heavily onto the perineum. The Finnish Grip also displaces the pressure of the baby’s head towards the clitoral area, and this causes increased numbers of tears in this area, often with serious loss of sexual feeling for women. These tears are considered to be less severe than anal sphincter tears (although partly this is because reduction of female sexual function is often considered to be of less importance than it is to the individual woman) – and again, we would not want for a moment to understate the catastrophic consequences of these – but what if there is another way?

What we know about perineal trauma is that women who birth on their backs, perhaps in lithotomy, are more likely to experience serious tears than women who birth in upright positions. Women who birth in water experience fewer serious tears, and the OASI Bundle cannot be used in water. The evidence around waterbirth reducing the incidences of severe tears has been well known for years, and we welcome hearing HCPs suggesting waterbirth to women who are worried about their personal risk of a severe tear, or who are at higher risk of it.

We also know that some obstetric interventions can increase the risk of OASI. For instance, inductions and epidurals lead to a higher chance of birthing lying down or in lithotomy, which as I’ve already discussed leads to gravity pulling the baby’s head more firmly down onto the perineum. However, the very low rates of severe tears in women who birth without pharmaceutical pain relief (allowing them to follow their instincts more clearly and leaving them with the sensations from their bodies to respond to), especially in low-medicalised environments such as home births or midwife led unit births, lead many to feel that there are other ways to reduce OASI without pinching a woman’s genitals as she is trying to push a baby through them.

Many midwives have noted how women will naturally close their legs together to slow the birth of the head – and yet how many women are encouraged to open their legs to “make space for the baby”? In artificial birth positions such as lithotomy, this is simply not possible, which may explain the higher numbers of tears which the Bundle is trying to reduce.

Margaret Jowitt has introduced an interesting theory that in upright or forward leaning birth, the baby’s head presses against the clitoris (again, as the pressure is spread towards the opposite side to the perineum), and in a spontaneous birth where the woman’s and baby’s bodies are working together the baby’s head could be “cushioned” by the the internal parts of the clitoris, (the bulbs and the crura), triggering it to enlarge and gently support the baby as the head passes through and out of the vagina. Midwife Joy Horner discusses the need for the vaginal and perineal muscles to soften and relax, much like is needed for comfortable love making, and a supportive, loving birth environment with a known and trusted care giver (continuity of carer!) who would not interfere with that oxytocin creation could explain why independent midwives have such low rates of OASI.

It is deeply worrying that we are seeing signs, during this OASI trial, that women are not being given information antenatally to ensure that they can give informed consent during their birth despite the fact that this is a key part of the Bundle. The Finnish Grip appears to be trying to rectify a problem which may well be caused in the main by over-medicalising birth and not supporting women to follow their instincts, and the damage that the Finnish Grip can cause with the associated increase in labial and clitoral tears may cause more women problems than would have suffered with anal sphincter tears. Instead of rolling out yet more intervention, perhaps it’s time to take a step back and look at supporting more women to birth in water, or to have more continuity of carer to ensure that during one of the most intimate periods of their lives, women and their carers can feel the deep and loving bond that even the very best, most caring midwives cannot be expected to develop when they meet for the first time in a hospital setting.

Make the Hospital Birth Space an Active Birth Space!

Aquabirths’ birth pools are designed to provide space and support for an active birth, but for women who do not want to use a birth pool but still want a hospital birth, or for the very rare woman for whom it’s not medically possible to use a birth pool, this fabulous video provides ideas of ways to use the hospital room space to lean, rock and move. Don’t miss it!

Organising safe and sustainable care in Alongside Midwifery Units: A Review

Oldham Midwifery Unit with Aquabirths birth poolAlongside midwifery units are defined as midwife-led units which are on the same premises as an obstetric unit (OU). They are usually next to the OU and may have come about following restructuring of the OU.

 

A follow on study from Birthplace 2011 investigated the way that alongside midwifery units are organised, staffed and managed, as well as the experiences of the women who use them and the staff who work in them.

 

The researchers looked at 4 different alongside midwifery units. They interviewed midwifery staff and service users, and also those in a management and organisational role. What became clear from the study was the fact that midwives working in alongside midwifery units were able to practice more autonomously, using their own clinical judgement. This is how all midwives, who are all autonomous practitioners, should be able to work, but obstetric units often discourage or reject this aspect of the midwifery role. Midwives also reported how they valued the work environment and culture, although the study did acknowledge that there was a need to ensure that midwives were supported to continue to develop their confidence, which is not a surprise as so many would have been trained in a far more repressive environment.

 

Another challenge for the sustainability of the alongside midwifery units was the fact that of all of the women who were considered to be good candidates to birth there, only a third ended up doing so. This study does not look at why this might be, but we know from feedback from women that very often they are simply not made aware of the midwife led unit in their area, so they did not have the opportunity to consider it for their baby’s birth.

 

Ultimately, Aquabirths would like to see the facilities which are commonplace within a midwife led unit such as birth pools, birth couches, mats and birthing balls, as well as the environment which is designed for calm, and to promote oxytocin, available as standard within all types of units, including obstetric units. There is no reason why these facilities could not be used by far more women, and we strongly believe that if a better birth environment was available to all, that more women would birth their babies with fewer unnecessary interventions. We hope that more research like this will encourage designers of all types of maternity units to create spaces which support both women and midwives to work together for better births.

 

Australian Midwives Supporting Waterbirth

An Australian study has looked at how midwives there perceive the value of waterbirth, and how well they are able to support it within their working environments.

The study outcome was very positive, with midwives reporting that both water labour and birth were very helpful to women, and they “documented benefits of reduced pain, maternal relaxation and a positive birth experience”.

Despite this, the midwives also reported, “…that policy/guideline documents limited their ability to facilitate water immersion and did not always to support women’s informed choice.” , a situation that we see so often over here in the UK. It is time to support women to access the many benefits to them and their baby that comes with immersion in water for labour and birth, and to treat each woman as an individual rather than as a “risk factor”.

The Australian study mentions that “negative attitudes” are a barrier to providing access to birth pools.  Quite rightly, there would be an outcry if “negative attitudes” prevented women from being able to have an epidural, and yet the risks of an epidural are well documented, whereas labouring and birthing in a birth pool has an extremely small list of concerns. One is, of course, what to do if a woman collapses while she’s in the birth pool. Tried and tested management guidelines are well established for this situation, which itself is extremely rare, but there is a worrying trend for women with higher BMIs to be denied access to a pool because they might be harder to bring out if they are unconscious. Another is the challenge of judging blood loss, but this is a skill that midwives who support waterbirth quickly learn. In “Revisiting Waterbirth”, Dianne Garland – expert waterbirth midwife – gives a helpful explanation of how the water should look when blood loss during or after a waterbirth is within normal ranges although of course there are many other factors such as how the woman is looking and feeling.

In summary, it is great to see a study showing midwives who are so positive about waterbirth, and the study seems to show that this is representative of many midwives in Australia, as is the case in the UK. The barriers come from attitudes from medical colleagues who need to be made aware of the work already done to deal with the concerns that they may have.