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’

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:

  • Thies-Lagergren, L., Kvist, L.J., Christensson, K., Hildingsson, I., 2011. No reduction in instrumental vaginal births and no increased risk for adverse perineal outcome in nulliparous women giving birth on a birth seat: https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/1471-2393-11-22

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!

There is only good plumbing and bad plumbing.

One firm touts their bath as having low profile (sic) fast flow plumbing.

Fast flow, low profile plumbing etc.  This is just unhelpful jargon.  Speed of drainage is a function of the diameter of the plumbing beneath the bath and the distance to the foul drain.  As our plumbers put it, gravity works the same and the only plumbing that counts is good, compliant plumbing.  In the past we were called out by hospitals as they had ‘other’ baths that had started leaking – all were around the plumbing area.  The low profile pipe inserted at an angle to the bath was the point of failure.  It is evident from their brochure (and the exclusions to their guarantees) that this weakness has been recognized if not addressed.

We designed our baths from the plumbing up.  We use only standard, purpose made plumbing fittings because these alone give the best fit, the longest life and are easily replaced by Estates and Maintenance in years to come.  We also introduced the use of the quarter turn ball valve as they are far superior to the gate valves used previously.  We are glad to see that this innovation has been taken up!
We also use waterless traps which still prevent odours and backflow but do not provide a reservoir for the build up of stagnant water.

Also, as our baths are designed to incorporate all the plumbing beneath the bath.  This keeps it all concealed but also the trap can be fitted very close to the bath waste as required by water regulations (BS5572), which reduces the length of ‘uncleanable’ pipework.  We note from ‘tother’ company’s brochure that their standard requirement is still only for trapping in the floor below.  The baths should be trapped in the room as close to the bath as possible without the customer having to order the special adapted higher steel subframe (another expensive fix and design ‘cul-de-sac!). The ‘tother’ company’s website used to advise that it was not necessary to put a trap on the bath, it was sufficient to just close the sluice gate valve.  I know from site visits that there were hospitals that fitted in this way.  Thankfully, we have been imitated in terms of  improved (if not ideal) trapping arrangements and better valves.

These so-called ‘fast flow / low profile’ drains are not only inferior in terms of durability, we have had comments from an NHS infection control department that

“This form of design has infection prevention and control implications with the potential for biofilm development”.

The sooner the ‘fast flow / low profile’ plumbing is seen for the jargon it is, the better.  It is trying to put a positive spin on inferior design and plumbing.

Bradford Royal Infirmary & the Canberra Birth Bath

Birth Rooms by AQB Pools Ltd A couple more pictures from the opening of the new Birth Centre and Bradford Royal Infirmary.

The hospital now has several of the Canberra model birth baths each in its own beautiful new birth room.  The Canberra birth bath is designed to be universal in that it can fit into most rooms and situations.   It is available on short lead times or from stock and costs well under £5000 (and discounts for 2 or more baths).

The photos came from Lorne Campbell / Guzelian.