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

 

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.

 

Waterbirth : Part of a World Movement

Revisiting WaterbirthBarbara Harper, founder/director of Waterbirth International reviews the second edition of Dianne Garland’s textbook ‘Revisiting Waterbirth: An Attitude to Care’ in the context of waterbirth practice around the world.

It is no secret that water is healing and that the use of water is an effective medium to facilitate changes in actual brain wiring. It is with excitement and great pleasure that I welcome the publication of the second edition of Revisiting Waterbirth: An Attitude to Care. Dianne Garland has continued to provide waterbirth education and training not only throughout the UK, but around the world. Our mutual passion brought us together for conferences, workshops and presentations many times. It has been my privilege to work closely with Dianne as a teaching partner in China, Spain, the Czech Republic, Israel, India and the United States. Her excitement about demystifying waterbirth is contagious, and the reader, whether midwife, doctor or mother, will experience that enthusiasm within the pages of this book.

There has never been a time in our combined history when the message and knowledge within Revisiting Waterbirth: An Attitude to Care has been more necessary. The misinformation surrounding waterbirth that Dianne and I have witnessed in different parts of the world is sometimes distressing and occasionally humorous. This book gives every practitioner an effective, informative guide to start a waterbirth practice and integrate that practice into any clinical setting. It also provides concrete examples and stories from those with whom Dianne and I have worked. The inclusion of detailed stories from practitioners and parents is a wonderful supplement to the new edition of Revisiting Waterbirth.

The use of water for labour and birth has increased exponentially since Dianne and I first started writing letters to one another in 1989. When we finally met in person 26 years ago in Kobe, Japan, at the International Confederation of Midwives conference, we excitedly shared documentation of the efficacy and safety of waterbirth. The demand for accurate, useful information and descriptions of experiences has also increased. When we first started our collaboration, waterbirth was referred to as a fad or a trend that would soon be gone. Women seeking the ease and comfort of water will continue to increase in every part of the world. Waterbirth is part of a world movement that seeks a more humane and gentler approach to childbearing.

The use of warm water immersion has long been seen as an aid for labour, making it easier for the mother to enter into and remain in a state of hormonal bliss. Today, there are well-designed studies that prove the efficacy of water for labour and the safety of water for the birth of the baby. Dianne’s experience as a hands-on midwife attending waterbirths, as well as her design and documentation of research, makes her the perfect person to lay the foundation of education for those who want to incorporate the use of water into maternity care settings. This book is also a guide for those who have already started waterbirth practice to improve their experience.

The message in this book is simple, straightforward and very hopeful. It is hopeful in the sense that more and more women are asking how to make labour less about ‘enduring the pain’ and more about creating a good, healthy and loving experience of birth for the baby. Women understand that creating a new human being is one of the most important jobs on the planet. The providers who serve those women need the encouragement that this book offers to step out of the routine medical care and become open to the possibilities that water can, indeed, change the course of a labour and should be utilized as a valuable tool for almost all women. The attitude with which professionals view a woman’s ability to give birth can either enhance or detract from her experience.

In 2014, the American Congress of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatricians (AAP) launched a campaign to put doubt about the usefulness of waterbirth into the minds of nurses, doctors, midwives and the public. Some US hospitals paid attention to the published and widely distributed ACOG opinion paper and halted their successful and incident-free waterbirth programs. Dianne and I travelled together to hospitals in Cleveland, Ohio, and Minneapolis, Minnesota, shortly after the article was published, to educate hospital staff and help reinstate waterbirth policies in these facilities. We were welcomed in these places and our efforts were rewarded when the practices were put back into place.

It is my sincere hope and desire that practitioners throughout the world are guided by the message in Revisiting Waterbirth: An Attitude to Care and start implementing protocols in more hospitals. All women should be offered the choice and opportunity to labor in water and birth their babies with the ease, safety and pleasure that water so beautifully provides. I also hope that our tandem careers continue to bring this message to every corner of the globe. As founder and director of Waterbirth International, I have relied on Dianne Garland to provide a multitude of research and documentation from the UK and have used this book in its earlier editions as a teaching tool and recommended reading for nurses, midwives and doctors.

Barbara Harper, RN, CLD, CCCE, CKC, Midwife
Founder/Director of Waterbirth International

Legionnaires Disease and Water Birth – An Update.

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
Ruth@Aquabirths

https://www.gov.uk/government/news/alert-after-legionnaires-disease-case-in-baby
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.

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.