At a recent conference attended by Ruth, a German midwife recounted how she used a much deeper container as a waterbirth pool . With this in mind, what do you, midwives and birth practitioners, think. It is not the bath that Ruth is stood in, rather its something to indicate depth. We have a design but there’s no point going into production if there is no call. Alternatively, we might start making it for the export market. Do let us know you thoughts.
When Leeds General Infirmary was chosen to appear on “One Born Every Minute”, they knew they had to make their water birthing facilities really special. Two of the student midwives Debbie and Coral were asked to find out more.
Speaking to Ruth and David, it was clear that Aquabirths knew how to adapt their pools to make the best of the room available. Particularly, it was their collaborative approach that helped the Leeds’ midwives feel that they could influence the design.
David drew up plans based on their ideas. Then, because they wanted something special, Mick the pattern maker made a wooden mockup of a birthing pool so that the midwives could try it out for themselves. They stepped in, laid back and suggested ways to make it work better for labouring women. Their suggestions led to Aquabirth’s unique heart shaped birthing pool.
Lobed birthing pools are particularly difficult to design because women of different heights need different places to sit or brace their feet. Another supplier had tried and failed, but our midwives trusted Aquabirths to make it work.
The plumber, Malcolm, then helped our midwives to understand the ins and outs of the plumbing involved. That helped them choose the longer lasting but heavier quarter turn ball valve, because as they said, “we’re harder in Leeds!!”
All this and Aquabirths completed the work in record time to make sure everything was ready for filming. The room is now an impressive mix of a generous heart-shaped pool, with LED mood and star lighting: the perfect home from home for labouring ladies.
Not every potential water birth room is a perfect fit for the standard birthing pool models. But at Aquabirths, we aren’t deterred by that. In Rotherham, our designer David’s first step was to look at our tried and tested pools and redesign the closest match so that it fitted the space.
After several visits where the midwives laid out their ideal plans, David shared his ideas – but not just on paper – he brought a life size cardboard model so that everyone could see for themselves.
By getting all the midwives, David and the Estates Manager in the room with the model, they were able to make sure the design lived up to the midwives’ dreams whilst meeting the Estate Manager’s safety needs. Getting everyone together got the best decisions made and everyone signed up to the plans.
The final design kept the plug socket more than three metres from the pool, enabling women to listen to their choice of music during birth. Without the bespoke design, that feature wouldn’t have been possible and it’s now one of the favourite features of the women who use it.
Please be clear this alert is NOT for baths and birthing pools filled from domestic or hospital hot water systems which are then emptied or pumped out when cooled or used.
This IS for heater filter units which re-circulate warm water.
This is not about these circulatory systems being innately dangerous either – just that the sanitization and effectiveness of all units now have to be checked to ensure safety before being hired out or used.
There is a potential for contamination if the unit is not fully disinfected, or the unit is not working properly or the users do not follow the strict instructions.
Investigation is under way. So, if you have one, lend one, or hire one, then contact your local Health and Safety Dept at your local authority to get advice on ensuring this awful situation does not happen to you, a loved one, or a customer.
Every good wish
Press Release Text:
Public Health England (PHE) and NHS England have temporarily advised against the home use of birthing pools with built-in heaters and recirculation pumps, potentially filled up to 2 weeks in advance of the birth. This follows a single case of Legionnaires’ disease identified in a baby born in this specific type of birthing pool at home. The baby is currently receiving intensive care treatment in hospital.
Samples taken from the heated birthing pool used have confirmed the presence of legionella bacteria, which cause Legionnaires’ disease. Tests are ongoing to establish if it is the same strain which infected the baby. This is the first reported case of Legionnaires’ disease linked to a birthing pool in England, although there have been 2 cases reported internationally some years ago.
NHS England has today issued a Patient Safety Alert rapidly notifying the healthcare system – and specifically midwives – to the possible risks associated with the use of these heated birthing pools at home. The alert recommends that heated birthing pools, filled in advance of labour and where the temperature is maintained by use of a heater and pump, are not used for labour or birth. In the meantime, a full risk assessment into their use is being carried out.
The majority of birthing pools used at home are filled from domestic hot water systems at the time of labour – these birthing pools do not pose the same risk and are excluded from this alert. There are no concerns about these types of pools as long as pumps are used solely to empty the pool and not for recirculation of warm water.
Professor Nick Phin, PHE’s head of Legionnaires’ disease, said:
This is an extremely unusual situation, which we are taking very seriously. As a precaution, we advise that heated birthing pools, filled in advance of labour and where the temperature is then maintained by use of a heater and pump, are not used in the home setting, while we investigate further and until definitive advice on disinfection and safety is available.
We do not have concerns about purchased or hired pools that are filled from domestic hot water supplies at the onset of labour, provided that any pumps are used solely for pool emptying.
PHE and relevant local authorities are investigating the infection control measures required for this type of birthing pool and local authorities will be working with the small number of companies who supply these heated birthing pools for use at home.
Louise Silverton, director for midwifery at the Royal College of Midwives, said:
Women planning birth at home using a traditional pool that is filled when the woman is in labour or using a fixed pool in an NHS unit are not affected by this alert and should not be concerned. Birthing pools in hospitals are subject to stringent infection control procedures and monitoring. Home birthing pools filled during labour come with disposable liners and are only in place for a relatively short time period, reducing opportunity for bacterial growth. Any women with concerns about using home birthing pools should contact their midwife or local maternity unit.
Legionnaires’ disease is extremely rare in childhood, with only 1 case in children aged 0 to 9 years reported in England between 1990 to 2011.The infection does not spread from person-to-person – people become infected with the bacteria through inhalation of contaminated water droplets.
These are some notes taken at the conference but they are really only a small representative sample of the practical workshops, seminars and main sessions attended. Most of all I met strong, inspiring courageous midwives, working sometimes against the odds , for good birth.
The strongest memory: Outside in the dark watching an amazing fire eating display by a midwife.
Quote of the conference: ‘I’ll give myself a treat and go and have a pee.’ Sara Wickham: “Having a pee is not a treat!!”
Jan Tritten and Robbie Davis-Floyd – International Activism
Jan Tritten’s Introduction:
Quote Harriet Tubman ( the anti slavery activist):
Barriers to YOUR dream include: Fear – the antidote to this is Faith“Every great dream has a dreamer”
Answer the call – stories of women around the world who have felt a call to midwfery and have had health and other problems until they answered the call.
- Lies and myths are rampant
- But we have dreams and callings to follow
- Birth is sacred ground
- We are called to a calling to change childbirth and to the benefit of both women and communities
- What is YOUR dream/vision?
- Don’t share dreams with negative people
- Take first step then next step – implement your dream one step at a time
- Dare to dream and dare to do it.
Participants in the workshop shared their stories:
NZ Chair of Council of Midwives shared their work in Banladesh setting up midwifery led birth practices with good effect.
Midwife in Philippines told her story of being called by the local Bishop to set up a clinic in the Church because of his concern for the health and wellbeing of local women ( the hospital care was not good enough)
She talked of the importance in her practice of trusting the Higher One she also said that ‘what you believe can be done’
Robbie Davis-Floyd talked about the IMBCI and the 10 steps for implementation of mother/baby human rights.
She talked about the 4 demonstration sites about the world. the full stories can be found on the IMBCI website
One is in Brazil, in a hospital which has now become a ‘high risk’ hospital for high risk women in the region. Even so their CS rate is 25%. Every woman there has a doula.
Then the amazing story of Mercy Mission in the Philippines with their birth centre in a poor district ( recently flooded they piled the beds up on top of each other so women could birth out of water and midwives wading in the water – coz women still coming to birth!)
They set up a maternity clinic in the disaster zone last year, in tents, with no water, no electricity and no sanitation, women traumatised and lacking food and essentials – but still implementing the IMBCI 10 steps. they maintained their 2% CS rate even within this situation. Amazing work – worth looking up.
Fear in Midwifery and Birth Workshop by Eneyada Spradlin-Ramos and Elena Piantino
Fear is not necessarily a bad thing – it can be a signal that a change is taking place, a call to pay attention, of the balance being changed. Fear is not necessarily a bad thing
Richard Davidson of Harvard re mindfulness – be aware of changes within yourself and room.
@ finding homeostasis for the brain
Homeostasis is the brain in equilibrium/balance. A perceived threat or stressor upset s homeostasis our balance – there is a response eg- fight or flight or fear. Then there can be a process of adaption to a new homeostasis.
In some contexts, the adaptive process makes midwives immune to situations (eg in a medical hospital context on large busy labour ward) that can upset or hurt women – midwives can act without compassion because they have adapted to their context and no longer feel the stressors and fear.
Adaptive mechanisms by care givers in stressful hospital environments does not do good for our care for women. It may protect us from stress as we don’t react to all the things happening but this means we will accept things as normal that we should not and do things that works without adaptive state but is wrong for the woman.
Fear alters our perception of risk and danger and it numbs empathetic responses
eg. homebirth – perceiving risk where evidence does not
decision making effected by emotional stress
Antonio Damasio, Neuroscientist found that brain damaged brains that cannot feel emotion also cannot make a decision. He said: ‘Every decision is made with a cognitive balancing and tipped by an emotional factor.’
Fear affects labour – blood for fight or flight goes to arms and legs but not for thinking. No blood to womb so contractions go off, fear tension pain cycle.
Coping with fear/uncomfortable emotions –
Short term coping mechanisms are:
Keeping busy, withdrawal, distraction and parties, letting off steam on other people (shouting and intolerance), expecting and working for the worst, abuse of substances etc.
Positive coping mechanisms:
Recognise triggers, know difference bet feelings and reality
Be aware re feelings/fear: is it history and memory ( what happened last time), is the fear coming from another person in the room, or what someone has brought into the room from elsewhere?
Emotions – is fear coming from in me, of from outside
Express/feel emotions, acknowledge and accept them – not block or repress them.
Other coping mechanisms: journalling, art therapy, red tent sessions ( safe spaces to share feelings without judgement or advice).
Red Tent specific experience:- talking stick. With stick – talk not interrupted. People can and do cry – but nothing said, no advice just accepted.
Twins – with Jane Evans
Notes pick up when Jane is talking about nutrition:
Everything is the same more but more!
Tweak the diet because pregnancy is not the time to completely change diet all at once.
Mums need plenty of protein for growth; Vit B and Vit C – via whole grains and meat. Complex carbs via beans and pulses.
Problems in pregnancy is often to do with liver problems – 2 babies twice the stress on the liver. So beans and pulses needed. If Mum not into lentils – suggest brown rice once a week as ‘medicine’, also soya, quinoa etc. As an aside: This is why students survive for years on beans on toast – cheap and nutritious. all there to support liver. Mums need to drink plenty of water.
Salt is important: good sea salt. Himalayan pink salt. Can test if woman low is slat ( sodium?) give her glass of water with half, the teaspoon of salt – if she not taste a glass of water with salt in it then she is low on sodium. Also if woman eating crisps and chips etc. say they are needing salt so instead of eating crisps and chips and processed food add salt to their food instead. found that having enough salt in diet/body reduces swelling odeoma and incidence of pre-eclampsia.
Make sure eating iron. if not meat eating make sure getting it anyway.
Nutritionist in group said: they have worked out woman needs 300 calories extra over normal diet when pregnant, breastfeeding need 500 calories extra. It will be more for twins – up to double? Tweak diet and change it gradually.
Keeping woman safe and healthy through the pregnancy
Bloods. not just check haemoglobin. also look at mcb, hcb
Reason Eg. You can have normal haemoglobin but low ferotin and have problems
mcb 70-99 normal so don’t iron supplement. If symptomatic then check ferotin. to supplement, avoid pharmaceutical iron whihc has bad side effects and not easily absorbed – try spatone ( favoured) also floradix. Food and nettle tea also suggested
Tweaking diet gradually: Eg.ple feel better after eating veg so encourage to eat more veg. This starts a good habit for feeding themselves and their children in the future.
32-34 weeks is the crunch point – at this point need to make a big issue of food. There is less room for food but need to be constantly eating – feeding the babies. If you can get through the 32-34 crunch time to get calories into woman and babies, then the pressure is off after and then they can eat back at normal pregnancy rate. If this is done then pregnancy normally goes to the natural term – whatever that might be. Normal term is usually the length of pregnancy for her previous (singleton) baby. (One example:1st baby 40+12, twins 40+11 days)
Concern: Induction of twins at 37 weeks – why do this when infant mortality risk of twins is at 37 weeks – so why induce at this dangerous time. why not wait until babies are ready to come out?
Obstetric practice. Concern re serial scanning. Research show that the thing that scans do is restrict the growth of the baby – so routine scanning is not good for the babies’ growth rate.
Palpating is good. then scanning when it is needed – scanning: need it when need it but not for routine. Midwife should palapate regularly: you are saying hello to the babies so they know you & you know them. Ask mum what she is feeling. Check differing sizes and think if differences are normal or pathological eg could it be boy/girl differing physiology. If you have concern offer scan to check.
Position of Babies for Birth. ‘Twin babies dance all over the place’ – 2 babies move about more than 1 baby. For birth the most stable is head down head down – but they can move as birthing. Eg. first baby head down for birth, when 1st come out then other baby will change position to birth – unless lying on back(obstetric method)then movement is restricted.
Leaving cord attached after birth of first. As contractions start for the second the cord starts closing down so cut cord and give baby to dad.
Timing between each baby – does it matter? Listen to the heartbeat if all OK – wait. For mum contractions usually restart after half and hour.so if baby ok why rush it? Heartrate (decelerations) can drop very low. if baby ok before prob ok – keep listening and if a continuing problem ( eg baby’s heart rate not pick up) then need to act. Between babies, cervix can pull in – eg to 5 cm but dilation is fast.
Placenta. Some women want to push out placentas.
Remember there is alot of placenta: ‘two handfuls of placenta’. Jane holds to cord of first baby ( which has been cut) as bearing down. Very satisfying to have one big one out. But often placentas will abut as one placenta can support the other. Placentas coming out separately not like as not know which one is which.
Remaining upright during births is what works – this point repeated several times.
About 25% of her twins babies have to have a cs despite their care.
The following notes are from an unscheduled session so I do not have name of the speaker, however, the following was too interesting to omit!
Quote from Grandma Beatrice, South Dakota who told twins birth story. She said she washed her hands then moved baby so baby born safely. Asked how she knew what to do, she replied:
‘Mother knows how to give birth, woman knows how to help’
Working in a remote area in Afghanistan setting up maternity services
Talked about how women generally treated – photo of a man with a whip fighting women back trying to get food.
Early marriage – photo of woman who aged 15 got married to 70 year old man had 10 children, he now dead.
She went with French NGO, decided to work with traditional midwives as they are always there – ngos will leave
But then Afghan Government adopted US/CMU programme to get rid of traditional midwives and train new set of midwives. They worry: it will be white uniforms and hosp care and this not work in poor remote areas.
Talks about looking at US aid programme and traditional midwfery program and how we bring them together. Lack of life choices: Choice for these women is having access to ANY care or none
‘We want local women and mothers to be the experts not us. We are wary of coming in and telling them what to do and what is happening.
Innuit in Northern Canada. How to preserve the tradition. Women not telling their story because they do not speak/write in English or other mainstream language.
Photo: This how women Inuit traditionally give birth, isolated in their own little hut/igloo. With fire in there. Very hot in there and steamy .
The amazing story of the Inuit people. Harrowing story of oppression and suffering. Then one community took birth back for themselves, replaced the medical man with a strong anouk woman. Made decision not to continue the medical practice of taking the women away from their communities for 6 weeks around birth, to boarding houses by hospitals thousands of miles away. They knew that some women might die if they not travelled to city hospital for 6 weeks – but the disruption and damage to family and community life so great that the community decided to take that risk. However, outcomes vindicated their decision: although no immediate access to cs – 8 hours (until recently, now 2 hours) – their outcomes have improved anyway. The old prescriptive hospital model did not work for outcomes either!
Sara Wickham – Homebirth Emergencies in Perspective
The more we deal in physiology the less likely we are to see an emergency. Also find that there are fewer emergencies the longer you are in practice Experience and normal physiology support safety.
Piece of recent research: proportion of cord prolapse associated with ARM
small study by Gabby-benziv, Mama, Wizintzer et al (2013)
Results: Cord prolapse:
62% after ARM
8% external cephalic inversion
and 8% related to intrauterine catheter insertion
Intervention carries risk
So risk of cord prolapse at home is vastly reduced because the key reasons for cord prolapse above are not done in home/physiological practice
Cases of ‘Safety Labour’ – women have a very long slow labour eg one case 40 hours becasue short cord and needed long labour to descend safely (and gave birth choosing lateral lie and leg up). Another example: slight heart defect and so need a long gentle labour – fast one would be too much.
Necessary Prep for Home emergenices:
- What is your learning style? saves alot of time to know this then you can make sure you are learning your way what you need to know.
- Support important – good backup?
- Supervision (choose a good one for you),
- Equipment, checklists and routines.
- Work with people you trust,
- don’t fear fear,
- doing the dummy run in your head (eg going thru what ifs in your head) – this is normal and lots people do it,
- asking for help ,
- checking with people.
Why aren’t all emergencies equal?
Top ten tips for emergencies on Sarah’s website free.
Sarah then went through the research showing the incidence and circumstances of emergencies. Basing it on a homebirth caseload of 25 per year. Some of the emergencies on this bais would be about once every 63 years! I was not able to get all the figures down but they were extremely interesting.
New Zealand research on pph at properly managed physiological 3rd stage
Research showed that as practitioners got better at supporting physiological 3rd stage then incidence of pph reduced. Also question of measuring blood loss/defining pph.
Incidence of pph in home environment based on 25 HB’s per year = 2-4 years; serious one every 5 years. This reduces with practitioner skill.
After looking at the incidence of main obstetric emergencies pertinent to the home environment, we can see that there are three essential skill sets that are most needed and most regualrly required:
PPH , Neonate resuscitation and Shoulder Dystoscia
So make sure you have these skills most practiced and uptodate
Other emergencies will happen between once in 20 and once in 50 years.
Sarah finally talked about her pph emergency kit which included a
laminated sheet which could be just given to the partner with instructions as to what they must now do e.g. ring hospital and say this . . .
All our baths come with a guarantee so that if something does go wrong and it’s our fault, we come and repair or even replace the bath.
We set up this business to make sure midwives and mums had the option of waterbirth at a sensible price and so we always look to make sure we’re as helpful as possible to midwives. In any business, from time to time, something goes wrong and it is how it is dealt with that tells you about that business. If something goes wrong with a bath and it’s our fault, we will get it sorted and as quickly as we can. We want women to have a good birth. That’s it.
A hospital sent us photographs of damage to a bath. They may not have been sure who’d manufactured, so they sent it to us and our UK competitor. Our response was to say, ‘that photo looks like our fault’ and have booked to get down there and repair. Our competitor sent it round to hospitals to try and cause bad feeling. You can compare the contrasting ethics.
The hospital he’d emailed certainly did. It backfired. This was their affirming response to us –
“I’m reassured to the fact we’ve opted for the correct product and the ideal manufacturer/service provider and partner.
I too dislike sabre rattling by competitors.”
Ruth and David and all at Aquabirths are there for midwives. End of.
Things you need to consider when installing a birthing pool – a Midwife’s guide.
As the demand for active birth – and water births in particular – increases, more and more trusts and birthing units are installing birthing pools. Here, David Weston, owner of Aquabirths in West Yorkshire shares his expertise and experience and gives guidance on “where to start”.
As with many things in midwifery, you have to start with the plumbing. Is there already a bath in the room where you plan to put your pool? Or at least a sink? If the plumbing is in place to begin with, it makes life a lot easier and the job a lot cheaper. One critical thing is the height of the existing waste water pipe.
Ideally, the waste water will leave the room either at, or very close to, floor level so that pipe-work from plughole to waste drain is at a steep enough gradient to enable the water to empty quickly. A valve and a trap need to be fitted in under the bath and it’s a case of getting them in before you run out of height. If the waste pipe is a few inches up the wall, then the bath will probably need to be raised, which can add to the overall cost of the build.
Space. When putting a pool into a birthing room, you might also want to consider what else you want in the room. Other room uses may impinge on the bath – for example, plug sockets for CD-players need to be at least 3m from the bath. It’s always a good idea to make contact with an experienced Birth Pool specialist very early in the process. Any company worth their salt will be willing to chat through your options with you, or be prepared to visit you, even before you have engaged an architect or project manager.
I have seen rooms with birthing pools left unused or – worse still – used as storage rooms! Allowing time to properly consider how best to equip the room with other equipment can avoid this. If you want a bed in the room with the birth pool, will you want to be able to move the bed in and out also? Will there be enough room to do so. You don’t want to find yourself in a position of not being able to offer the birth pool to women who want it because someone rammed it with a bed and the estates office have told you it can’t be used.
Colours and features. Gone are the days of “it comes in white…or white” A birthing bath can be any colour and any shape you want and many of the baths we have installed have been adapted to suit the needs of individual midwifery teams. If you have a “dream” birthing pool in mind, don’t be afraid to ask. Modern moulding techniques mean that bespoke baths are much more affordable than they were ten years ago.
When it comes to taps, choice can be a little more limited because of the various regulations that apply to hospitals. Any good birth pool company will know their way round these regulations and should still be able to offer you a number of alternatives. It is probable that this is something that can be sorted by the hospital’s Estates Department. You can also request additional features and modifications such as LED lights inside the bath, a choice on the position of the waste outlet and even the addition of an anti-bacterial gel coating.
Make it a Team Effort Involve the Estates Department as early as is possible / helpful to you. They may be able to help with much of the above and undertake some of the works to make your budget go as far as possible. We do offer an installation service for our pools so you can be sure it is fitted correctly. However, budgets are often stretched and it should be possible for the hospital’s own Estates Department to fit the bath. Make sure your pool comes with instructions and telephone support from the birth pool provider.
If you’re not sure, ask. A birth pool may be one of your biggest investments of the year, so don’t be afraid to ask questions throughout the process. Once the bath is in, it’s sometimes too late to make changes so keep the channels of communication open throughout the design, build and installation process. A good birth pool company will have time to talk through your options and be willing to answer any questions you have. It’s a good idea to have clarification on points you are unsure of in writing to avoid any confusion or surprises later down the line. If you discuss something with your birth pool provider on the phone, drop them a quick email afterwards to confirm what you agreed. Don’t assume that because you know exactly what you want, they do too – they’ll only know if you tell them.
And finally – once your pool is installed, make a bit of noise about it. Be sure to let the local press know about your fabulous new facilities (your birth pool company may be able to help you with this) and invite local stakeholders, community midwives, doulas, GPs, practice nurses and mums to be to come and take a tour of your new birthing room. You wouldn’t buy a new pair of shoes and never wear them, likewise don’t commission a pool and forget to show it off – that way it will get used more frequently, you will get your money’s worth and you will see an increase in the number of mums enjoying your new birthing pool.”
The Dunoon model compact birth bath installed at Royal University Hospital, Bath as part of their refurbishments, which were envisioned and overseen by SR Architects. The Dunoon model is designed to keep all the room of a birth bath for the mum-to-be but to be efficient in its use of space. If you have small birth room or space is tight, then the Dunoon birthing pool is ideal. And with a price tag well under £3000, it is also suitable for hospitals that need to fit out several birthpool rooms. As with all Aquabirths baths, this bath can be customised and is flexible in its design – the hatch can go either side, it can be fitted side-on or end on. And, as with all our baths, it is a one-piece bath with a single-surface for strength and superior hygiene control.
I doubt if there is a maternity unit in the UK that isn’t strapped for funds. Savings always need to be found! But please don’t scrimp on the installation of the birthing bath – this is a job for a qualified plumber and not a general fitter. This is not a way of pushing our installation service but simply because we’ve just had to tidy up a mess left by a contractor who didn’t install the bath properly.
It is very important that the bath you have bought, paid to be delivered and installed is put in properly to avoid extra costs and problems down the line. Make sure Estates or someone ensures the contractor follows the instructions. If you have queries, ring us. You could have a site visit before hand so that we can discuss installation; you can also book for our plumber to be present at installation to offer guidance, at the very least, you could arrange for him to be present to give phone support. The cost of a site visit (which is only for mileage and time) is discounted from the purchase price (up to a maximum of £200) in any case.
We understand that hospitals will want to make saving where they can but, as we know with a local hospital, the installer put the bath in wrongly and with no consideration of the midwives who will have to use it. This has caused extra expense, hassle and time-wastage trying to sort it. Othertimes, the incorrect trap has been used so that Infection Control are unhappy.
A very useful paper according to none other than Beverley Beech. More evidence (as if more were needed!) for the need for caseloading community midwifery. The link below is to the article of the same name as the title of this blog post.
It can also be found on the blog Bornstroppy.