Update on Taps

Some guidance on taps

We have found, within the NHS and the UK setting, taps are best left up to specialist suppliers.  We know that the following have been used recently within UK hospitals and with our baths.

Twyfords, Armitage, Horne, RADA (https://www.radacontrols.com/en/products/all-products/rada-sense-bath-t3, are increasingly popular)  and so forth are the specialist tap manufacturers whom we know have been used and are being used by bath customers.

The Morecambe Bay Trust have used the following at Lancaster, Kendal and Barrow

The Trust favour two of the following so that there was a double supply of mixed supply hot water.  The reason being that 22mm taps that are HTM compliant are very difficult to source and a 15mm tap would take too long to fill the bath.

http://www.idealspec.co.uk/catalogue/bluebook/brassware/contract/contour-21/contour-21-single-control-mixer-and-15-23cm-spout_p351.html

Having spoken to the plumbers used at Leeds, they installed Markwik, which are available for IPS and bath mounting. At York, they used the Horne Optitherm and a Markwik tap again (pdf sheets attached).

The Rada Sensor tap is becoming increasingly popular as the users do not even need to touch the controls.  The following is for the electronic TMV itself.

https://www.radacontrols.com/en/products/all-products/rada-acu-t3-dmv-with-225mm-spout/

The ‘older’ model is

https://www.radacontrols.com/en/products/all-products/rada-sense-bath-t3/ https://www.radacontrols.com/media/60312/rada-sense-bath_shower-t3-dmv-2018.pdf

 

Their brochure is

https://www.jhplumbingdepot.com/system/brand_attachments/956/original/Rada_healthcare_brochure.pdf

 

Other hospitals and plumbing engineers have advised that they used a 22mm / ¾” tap without an inbuilt Thermostatic Mixer Valve and put in a 22mm TMV earlier in the plumbing and within the stipulated distance from the tap.  This enabled them to have HTM64 compliance and use 22mm supply to ensure a quicker filling.

Wonderful Wednesday:  Waterbirthing Tilly

Tilly's father David holding a newborn Tilly. David is a white man with brown hair and glasses and Tilly is wearing a white garment. There is a red wall behind them with a mirror which reflects David.By Aquabirths’ Owner and passionate waterbirth and birth activist Ruth Weston

I woke to mild but real contractions. I was going to birth the baby today. It was clear as soon as I started moving around that she was  not going to hang about. I rang the midwife about 7am and it was Madge, community  midwife for my previous baby and we were  both delighted.

My two older children were despatched to the caring hands of a friend.  I was then in the living room and the contractions were sharp and angry. I put on punk music and was dancing round the room shouting f*f*f* – something I would never do!  I turned to my husband, David, and shouted at him for having the easy part, telling him that it was alright for him. I was so angry! My hubby smiled, this had happened before; he knew labour was cracking on.

The homeopath arrived and gave me a remedy. Between that, and releasing all that emotion, the contractions changed, the sharpness had gone and they were easier. The music changed.

Midwife Madge arrived about 9am. I felt that I wanted to go into the pool which was waiting for me upstairs. But I was uncertain, should I? “Go!” they said. So I scarpered upstairs between contractions, chased  by everyone else, and dived into the pool. “Ahhhh!” It was bliss. It was bliss. I wanted big band and blues music now, swinging my hips and groovin’ in the water. And singing along. Indeed everyone sang along and there was quite a choir: The second midwife had turned up with a colleague who wanted to observe a waterbirth and a student who had never seen a  birth before! I was worried that because the contractions were  now so easy that there was something wrong, I was reassured that the contractions were strong. All was well, so I carried on groovin’.

Then quite suddenly everything changed again. I needed quiet. I wanted the music turned off and the chatter stopped. It was close to birth now, it felt really sacred and I felt inside I was treading on holy ground. My homeopath started reading the prayer on the wall by the pool.

But then a little while later (I have no idea of timing) I sat back on my heels, turned to Madge and said “I could have had this baby a few contractions ago but I don’t like this last bit. It hurts.” I can’t remember what Madge said, something about babies have to be born, and that it does hurt but it passes, seeing baby and that everyone wanted the baby out because we wanted lunch! My homeopath meanwhile had dived for her kit and gave me a remedy! And then I simply birthed the baby. And it did hurt and I roared! But it did not hurt as much as I had dreaded. Two contractions and she was there. There was a moment of chaos as I had wanted to lift the baby out of the water and someone else had whipped her out quickly and I was roaring “Where’s my baby! Give me my baby!” And turning around and around getting the cord tangled. And baby was crying because I was crying and there was water and towel and people everywhere! Apparently the student was crying and getting hugs too.

This picture is taken after I birthed the placenta and was being cleaned up. It is my favourite photo! And this lovely baby Mathilda Ruth Melangell is 21 today!

As a postscript. If anyone wants to know why I am so passionate about birth and so angry at some of the culture and practices going on – here is the reason. No woman or baby should be robbed of the opportunity  of this wonderful, wonderful, life-changing experience.

March 31st, 2021

Aquabirths Research Review: Women’s experience of Waterbirth

Photo of Aquabirths birth pool to illustrate the article on women's experience of waterbirth

Aquabirths Research Review: 

Title: “A systematic meta‐thematic synthesis to examine the views and experiences of women following water immersion during labour and waterbirth.”

Authors: Claire Feeley, Megan Cooper and Ethel Burns

Published in the Journal of Advanced Nursing (Link)

Review by Emma Ashworth

Background
A common complaint about research into midwifery and obstetric interventions is that they seldom include the views and lived experiences of the women and people who have them. The evaluation of outcomes are usually limited to physical outcomes, not psychological ones, which reflects the dominant culture of prioritising physical injury over psychological injury and the common adage, “at least you and your baby are healthy”. There is also often a prioritisation of the physical health of the baby over the physical and psychological health of the mother or birthing person, which can leave them feeling like they are of less or little importance, or simply a vessel to grow a baby.

It is therefore very refreshing to read this paper, which has gathered together what information we do have on how women feel about waterbirth into one place. Waterbirth is safe for babies, as has been shown time and again (see our blog for more research reviews) and now we have a wonderful collation of the data on the psychological safety and benefits of waterbirth to the birthing woman or person: Women’s experience of waterbirth.

What did the paper look at?
This particular piece of research has gathered together women’s experience of waterbirth under three main themes which they describe as: Liberation and Self‐Emancipation, Synergy, transcendence and demarcation and Transformative birth and beyond.

What were their findings?

  • Pain relief
    Firstly they looked at the effectiveness of water as pain relief. They note that, “While the experience of pain is subjective and influenced by several factors, the provision of adequate pain relief in a timely manner to suit the needs of women is a hallmark of respectful maternity care”. It is also a legal requirement, under the European Convention on Human Rights as well as International Law. No one should be left in pain when suitable pain relief is available, and refusing a large bath but offering opiates is clearly unlikely to be the safest option for many women and people.

The paper discussed the fact that the sense of pain during labour can be increased if a woman feels anxiety or fear. Warm water is a natural relaxant for most people, and this increase in relaxation is thought to be instrumental in reducing anxiety, and therefore pain. The paper states, “Both the water and pool itself facilitated women’s physical and psychological needs during labour and/or birth, including offering effective analgesia.”

While the birth pool may not have taken away all the pain, women explained that it “softened the intensity” of pain, supporting women’s self-belief in their ability to cope with labour.

Key takeaway: Birth pools offer safe and effective pain relief without the side effects that come with pharmaceuticals. Birth pools support the physical and psychological needs of birthing women and people.

  • The protection of the birth space
    The paper describes the experiences of women who gave laboured and/or gave birth in a birth pool as, “liberating and transformative experiences” and that women felt “empowered, liberated, and satisfied”.

An important benefit to the birthing woman or person was the “demarcation” of their space, creating a “safe haven” and a “cocoon”.

“…the pool itself […] provided a physical demarcation of the women’s space in the birthing environment/room. The birthing pool offered a safe and private enclosure in which women were able to let go of inhibitions, physically and psychologically separate themselves from the outside world while also facilitating their ability to go in – flowing ‘with’ labour rather than fighting against it. In turn, this enabled them to transcend into an altered state of consciousness where time and place lost their meaning, indicative of a deep internal connection to ‘being’ rather than doing.”

Key takeaway: The physical presence of the birth pool meant that women felt safe and protected, and supported them to work with their bodies, facilitating a higher chance of physiological birth.

  • The transformative effect of a positive birth
    The sense of achievement that women felt was a very strong theme in all of the research that was summarised in this paper. It describes, “… vivid feelings of empowerment, ‘victory’ women ‘claimed’ their birth’, rather than ‘being delivered’ of their baby.”

Catching one’s own baby in the water was hugely empowering for many women, but even when this didn’t happen the sense of achievement was profound, with many women stating that they wanted to do it all again and that a birth pool would be imperative at their next birth.

This sense of achievement went beyond the birth, and led to a transformation that continued into the postnatal period, showing that women’s experience of waterbirth has far more value than ‘a nice birth experience’.

“The next day I was sitting, suckling my daughter, with an oversized aura, super proud of me, my experience, and all that. And I think it’s fundamental to have a positive birth experience.”

“The difference in me mentally was unbelievable; I was definitely a lot mentally safer this time. I honestly believe [the water VBAC] turned me into supermum.”

Key takeaway: A positive birth leads to safer women and babies, both during the birth and afterwards. It can transform how women and people feel about themselves, and their relationship with their babies.

Summary
This important paper gives us yet more invaluable information on the importance of ensuring that every woman or person who wants to labour and/or birth in water is supported to do so. It clearly describes the powerful and positive effect of water on physiological birth, and on the psychological well-being of mothers and birthing people. The paper concludes that, “We recommend maternity professionals and services offer water immersion as a standard method of pain relief during labour/birth.” Aquabirths completely agrees!

Aquabirths Research Review: Better outcomes for women and babies when they labour and birth in water.

Aquabirths Canberra Birth Pool

Aquabirths Research Review: 

Title: “Maternal and perinatal outcomes amongst low risk women giving birth in water compared to six birth positions on land. A descriptive cross sectional study in a birth centre over 12 years”.

Authors: Hannah G. Dahlen, Helen Dowling, Mark Tracy, Virginia Schmied, Sally Tracy

Published in the journal ‘Midwifery’ (Link)

Review by Emma Ashworth

Background
One of the limitations of research is getting enough data to really represent reality. This piece of research into the safety of waterbirth used data which was collected over 12 years, and considered the births of over 6,000 women. This gives us a really good, clear picture of what the outcomes really are. What the researchers have discovered is invaluable information for those looking to support women and people with their decisions around labour and birth in water compared to labour and birth on land in different positions, and supports the ongoing evidence that waterbirth is extremely safe and is an excellent way to support physiological birth.

What was the research looking at?
This research compared multiple labour and birth positions on land and in water. The aim was to see what difference six birth positions on land, and birth in water, made to perineal trauma, postpartum haemorrhage (PPH) and five minute APGAR scores.

The land birth positions were on a birth stool, semi recumbent, kneeling/all fours, lateral, standing and squatting.

Where was the research undertaken?
This data for this paper came from 12 years of maternity notes in an alongside Australian birth centre. The birth centre was next to an obstetric unit, and during the period of time that was looked at 8,338 women laboured there, and of these, 6,144 gave birth in the birth centre, the rest being transferred to the obstetric unit. Only the data of those who gave birth at the birth centre are included in this paper. The interesting thing about this birth centre is that both midwives and obstetricians work there, with the obstetricians working on a private basis, although the risk profile of the women for both types of birth workers were the same.

How accurate was the data?
The data that was used in this research paper was described as “detailed descriptions of the birth positions women had assumed for the birth as well as recording; parity, length of first, second and third stage of labour, blood loss, accoucheur, perineal trauma, sutured or not sutured, shoulder dystocia, physiological or active third stage management, use of oxytocis for third stage and analgesia.”

What were the outcomes?

  • Perineal trauma

Water birth showed a lower rate of perineal trauma compared to all of the land birth positions, although only labour and birth on a birth stool reached statistical significance. The authors discuss this, pointing out that other research has shown that birth stools can lead to higher rates of perineal trauma, although a study in Sweden1 did not show this to be the case. The difference in the Sweden trial was that the women were encouraged to not stay on the birth stool for longer than about half an hour which may have lessened the risk of oedema, as oedema  may be caused by sitting in the same position for long periods, and it may lead perineal tissues to be more prone to injury.

  • Post partum haemorrhage (PPH)

Defined as blood loss over 1000mls, water birth led to lower rates of PPH compared to all of the land birth positions, although again only rates within the birth stool group were statistically significantly different. The authors concluded that the increased rates of PPH for those women who used a birth stool is likely to be caused by perineal damage rather than bleeding from the uterus. It is also harder to judge the loss of blood in the pool compared to in a land birth which may have led the waterbirth blood loss rates to have been under or over recorded.

  • APGAR scores

The APGAR outcome that was looked at was a score of less than or equal to 7. All of the land birth positions led to more APGAR scores of less than or equal to 7 compared to water birth, although the only position where this reached statistical significance is the semi recumbent position. This may have been caused by women being asked to move into this position if there was a concern about the labour, rather than the position itself causing the lowered scores.

Summary
Although outcomes for waterbirth were better than for land birth in all areas, these differences rarely led to statistical significance. However, this does show that the outcomes of waterbirth that were looked at in this paper (PPH, perineal trauma and APGAR scores less than or equal to 7) were at least as good, if not better, than all of the land birth positions that were considered.

We can therefore conclude from the data in this paper that labour and birth in water is at least as safe as labour and birth on land, when looking at the specific parameters considered in this research paper. This is helpful to midwives and doctors wishing to demonstrate the safety of waterbirth to their Trust, and to support more midwives and doctors to be trained in supporting labour and birth in water.

References:

Is water birth safe for women and midwives during Covid-19?

There has, very understandably, been a huge amount of concern about whether different maternity care practices increase the risk of transfer of Covid-19 between the woman giving birth and those caring for her. In some hospitals, the use of gas and air was stopped for a while, and in many, water births have not been supported for some time.

The two most commonly referred to concerns about Covid-19 and water birth were:

  • As virus particles have been found in faeces, could water birth increase the risk of faecal transmission?
  • Could water vapour in the pool room transmit virus particles more efficiently than in dry air?

It is also important to look at whether water birth can reduce the transmission of Covid-19. Does birthing in water reduce the risk of transmitting Covid-19 between birthing mother and midwife?

Consideration of theoretical risks of water birth with Covid-19

Let’s first look at the possible risks. According to the WHO1, Covid-19 is transmitted through a) droplets in the air (created by sneezes, coughs, breathing and so on) which can be breathed in by other people, and b) by the droplets landing on a surface which are then picked up, eg by someone putting their hand on them, followed by them transferring the virus particles to the face, allowing entry through the eyes, nose or mouth.

Although, according to WHO, there may be Covid-19 virus particles in faeces, only one study has been able to culture it and there have been no reports of faecal-oral transmission.2 Furthermore, faeces passed in the pool is immediately in contact with the chlorinated tap water and enveloped viruses such as Covid-19 are not able to survive for long in chlorinated water. It’s not clear from this WHO data how long it might survive in chlorinated water (it only refers to de-chlorinated water), nor how chlorinated the water needs to be (as the tap water’s chlorine does evaporate over time). However, even without this data it seems that provided that normal care is taken with the water and hand and body hygiene, there is a much lower chance of a midwife contracting Covid-19 from a birthing woman through the water compared to through the air. Furthermore, when the baby is born in the presence of faeces (which, of course, is a very common occurrence), the effect of dilution and washing of the mother’s genitals by the water may decrease the chance of transmission at the point of birth from woman to baby, but to date there is no evidence on this point.  However there is evidence that rates of the newborn contracting other infections such as staphyloccus and e-coli are no different in land and water births. This does not mean that Covid-19 would be the same, but the effect of dilution in the water is likely to be an important protective mechanism.3

The second question was whether Covid-19 could be more easily transmitted through the air within the possibly more humid environment of the pool room. The research on this, as with so much around Covid-19, is very minimal and contradictory. It also tends to look at humidity in terms of weather, not humidity inside a room. There is some evidence that increased humidity may make the virus harder to transmit, but other research says that this is not the case – but social distancing, natural when a woman is labouring in a pool of water, PPE and hand hygiene might have far more impact anyway.

Consideration of theoretical benefits of water birth with Covid-19

We have already considered that it is likely that if there is any possible faecal-oral transmission route, water birth will reduce the chance of this. In addition, we believe that there are other possible benefits to water birth in terms of reduction of potential transmission of Covid-19 between mother and midwives.

The birth pool, by its nature, means that for many labour positions there is a greater distance between the birthing woman and the midwife, which could help to reduce the chance of cross infection. The water surface is a large part of the space within the room, and virus landing on the water would not be a possible route for surface to face infection, unlike a maternity bed.

Using bed birth as a comparator it is possible to see water birth as being as safe as a land birth. In summary, when looking at the safety of water birth in the context of Covid-19, we must not lose sight of the benefits as well as the possible risks – and not take away this vital form of pain relief as a knee jerk reaction rather than thinking through the comparative risks of land and water birth, physiological and medicalised birth.

 

References:

  1. WHO: Water, sanitation, hygiene and waste management for the COVID-19 virus: https://apps.who.int/iris/bitstream/handle/10665/331305/WHO-2019-NcOV-IPC_WASH-2020.1-eng.pdf
  2. WHO on faecal-oral transmission: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/question-and-answers-hub/q-a-detail/q-a-coronaviruses
  3. Fehervary et al, 2004, Water Birth: Microbiological Colonisation of the Newborn, Neonatal and Maternal Infection Rate in Comparison to Conventional Bed Deliveries: https://pubmed.ncbi.nlm.nih.gov/12955529/

 

 

 

Waterbirth Reduces Vaginal and Perineal Tears – New Report

Aquabirths Canberra birth pool iimage
Picture: Lorne Campbell / Guzelian

It’s always exciting when new research into Waterbirths comes out because they’re fairly few and far between. In this case, it’s a report from the USA1 where waterbirth is less well supported than it is in the UK and Europe. The report looks at a variety of outcomes, including how waterbirth reduces the incidence of vaginal and perineal tears, postnatal haemorrhage, Apgar scores and neonatal unit admissions.

Although this wasn’t a randomised control trial, it was a high quality retrospective study which looked at matched comparisons, so ‘like for like’ women with similar pregnancies and risk factors were properly compared. This means that the outcomes can be relied upon to be accurate.

Most outcomes were the same between the two groups (which were women who birthed in water and women who birthed on land). There were no differences between the numbers of women who experienced significant blood loss, but also there were no statistically significant differences between the numbers of babies admitted to the neonatal unit, and Apgar scores were similar between the groups.

There was one big difference though. The numbers of women who experienced first or second degree tears to their vagina or perineum were significantly reduced when the women laboured and birthed in water.

Aquabirths have previously written about the challenges of reducing vaginal and perineal tears, and our concerns about the OASI bundle. It is so important to consider the use of birth pools when looking to reduce the numbers of women who are experiencing these serious birth injuries, which can be life changing. Increasing the number of women who are accessing water to labour and birth in hospital, in midwife led units and at home is a low cost way for Trusts to support normal physiology and reduce the number of unnecessary birth injuries.

The evidence on the safety of waterbirth is overwhelming. We know that birth in water is safe for women and babies. We know how to support waterbirth for women who have a high BMI, are being induced, are having a VBAC or who are carrying Group B Strep. We know how positive and empowering waterbirths2 are for women, and we know how powerful the pain relieving3 aspect of a birth pool is.

So many obstetric units’ birth pools are underused. What can you do to increase the numbers of women using it? Can you take that on as your task for the month?

References:

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