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

 

Oldham Birth Centre: Nurturing Families

Oldham Birth Centre – A Place to Want to Labour!

Aquabirths birth poolOldham, in Greater Manchester, UK, has created the most stunning, supportive and effective birth centre which is family-centred and woman friendly. Designed to nurture women and birth, creating a safe, positive and caring space for the whole family – including other children, who can be present at the birth of their sibling.

Designed to support the physiology of birth from the ground up, the Birth Centre rooms do not centre around an obstetric bed. Instead, they feature slings, balls, mats, Softbirth couches, adjustable lighting and the stunning Aquabirths birth pool, with a large family bed available for parents and baby to rest in after their little one is born.

The Oldham Birth Centre’s philosophy of care is key to the success of this midwife-led maternity unit. Midwives are trained in hypnobirthing techniques, aromatherapy, acupuncture and using water to support positive, safe, physiological birth. Minimising adrenaline is key to maximising oxytocin, and maximising oxytocin is key to birth progressing well, so the whole room is designed to be calm and to help everyone to relax. An aromatherapy diffuser by the door greets the birthing family as they arrive, and the scents in the air, the dimmed lights offset by coloured bubble lamps and the Aquabirths birth pool gives a sense of walking into a spa.

Oldham Birth Centre Wall Painting
Oldham Birth Centre Wall Painting

Midwives describe seeing women sitting in a chair and looking around, and visibly relaxing. A kitchen is available for all to use, so birth partners can help themselves to drinks, and they can make their own snacks. Midwives make it quite clear that this space is for them to use, which is an important part of helping everyone to relax and continue to reduce any adrenaline levels.

The Oldham Birth Centre is not an extension of the labour ward, but instead is designed as a birth centre for the families of the city. While there are strict criteria for straightforward access to the unit, if a woman wants to birth there she can attend a Birth Options Clinic where their choice of place of birth is discussed, and the woman will be supported by the midwives.

The unit itself is nothing without its midwives, and the midwives at Oldham are hand picked for their inbuilt nurturing nature – not a trait which can be taught. Diane watches the student midwives who show an interest in physiological birth and support women’s choices. Those who wish to become part of the community/birth centre team are encouraged to apply.

Oldham Birth Centre is not unique, but it is unusual and it is beautiful. The women and families of Greater Manchester are extremely lucky to have this wonderful facility with its fabulous midwives.
The unit has a video on You Tube which showcases the birth pool and other facilities: https://www.youtube.com/watch?v=2wOHqJfLhGg

Better Births in Powys – Supporting Women, Improving Care

Powys delivering better births
Ruth Weston of Aquabirths in the new Aquabirths birth pool installed in one of Powys’ birth centres.

Powys: Supporting women and supporting Better Births.

In the heart of Wales, in one of the most rural areas of the United Kingdom, lies the beautiful county of Powys. In this stunning region the recommendations of The Birthplace Study and Better Births are being wholeheartedly implemented. In extraordinary contrast to some areas of the UK, Powys has determined to ensure that Midwife Led Units are recommended as the optimal birth place for healthy women and babies, provided they are happy to birth there – supporting women in their decisions and supporting Better Births.  20% of women give birth in a midwife led unit in this area, compared to 14% for the rest of the UK.

Powys has 6 midwife led units across the county, limiting the distance that women need to travel in labour, increasing safety for women and babies and reducing the stress on families at a time where the birthing woman needs to be able to focus on her job at hand.  In addition, Newtown, one of Powys’ towns with a birth centre, has recently celebrated  the huge achievement of obtaining funding to run sonographer services local to where women are, reducing the travelling distances for women by 3000 miles a year!

Newtown has also used its funding to add in a permanent Aquabirths birth pool, and a double bed so that new parents can snuggle up together with their baby after the birth, rather than being separated at one of the most profound times of their lives.

Well done Powys – you are an inspiration!

Guest blog by Emma Ashworth