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!

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

 

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

I’m Group B Strep (GBS) Positive. Can I have a Waterbirth?

GBS testing is not routinely offered to women in the UK.  This is because it is considered that the high rate of carriage compared to the low rate of infection means that the harm done to women and babies in offering antibiotics to every woman who is carrying GBS would outweigh the benefits.

However, some women do end up being tested for one reason or another, and those who find that they are carrying GBS are often then denied access to water during their birth (unless they’re at home, in which case it’s always the woman’s own decision). Aquabirths asks, “Is this a reasonable position for trusts to take?”.

Many trusts are open to women birthing in water and some are not, and within trusts some midwives or obstetricians will deny women access to the trust’s pools, and others will be completely happy to support women who want to use a pool for their birth. What’s going on?

There is limited data on the impact of waterbirth on how many babies born to women who are carrying GBS, but what data there is shows either a reduction in the numbers of babies born underwater who are infected with GBS, or no statistical difference, but with a trend towards a reduction in affected babies who are born underwater. This is despite the fact that the water in a pool birth could have high levels of GBS in it, and therefore the theory is that the water is essentially washing the baby and mother, providing some increased level of protection compared to babies born on dry land. (1)

An article by JS Cohain (2) states that infection with GBS was 1/4432 in babies born underwater v 1/1450 in babies born on land – that’s three times as many babies becoming infected with GBS when they’re born on land than babies born underwater! The article discusses the reasons for this, including considering whether it might be “a massively successful international campaign has covered up the reporting of all deaths and disease from GBS after waterbirths.” There’s nothing like covering all bases!

Even though the evidence on GBS and waterbirth is limited and more studies are needed, if the trend was the other way – that more babies seemed to be infected with GBS when born in water – there would be no doubt that there would be a huge push to try to ban birth in water! Given that the opposite is true, and the best data that we have shows a trend towards fewer babies being infected with GBS when they’re born under water, opening up water birth to women who have found that they’re carrying GBS is something that every birth centre and obstetric unit should support.

Article by Emma Ashworth.

Many thanks to Dianne Garland for her help with this article.

References:

(1) Springer Link, “Water birth: is the water an additional reservoir for group B streptococcus?” 

(2) Pubmed, “Waterbirth and GBS”

Further Reading:

AIMS GBS book, “Group B Strep Explained”

RCOG “Group B Strep and Waterbirth”

Practicing Midwife for the GBSS, “Waterbirth for women with GBS: a pipe dream?”

Dianne Garland’s book, “Revisiting Waterbirth” is due out in April or May 2017

Fantastic Looking Birthing Pool

 

We had an email that came via the midwives of the Morecambe Bay Trust in response to our installation of a Canberra birth bath at Barrow (Furness General)

To whom it may concern,

I have seen pictures of the new birth pool in Furness Hospital on your website it looks fantastic. We are looking at developing  a water birth service in our hospital in Limerick in the Republic of Ireland.

We would like to get some information and details of the birthing pool.

I would be delighted if you could supply some information in relation to the birthing pool company and specification that was used.

Regards

Best birth bath ever

Waterbirth Conference 2015

A packed-out conference on waterbirth and normality held in Shipley, with such speakers as Dianne Garland and consultant midwife Alison Brown.  A fuller report to follow but here are some of the tweets…

 

 

 

There was also the launch of BirthSoft for reasonably priced birth couches, mats, etc.

 

Special Offer on Birthing Pools for Wales

Aquabirths in Wales ~ Aquabirths yng Nghymru

 We’ve opened an office in Wales! To celebrate, Aquabirths is offering a range of large discounts on birth pools to hospitals in Wales and hospitals serving Wales: Chester, Shrewsbury, Oswestry, and Hereford.  This may be just the opportunity your service needs to increase access to this popular birthing option for women.

You can save 20% off Canberra, Venus and Heart-shaped model birthing baths.  York baths will have free delivery.  As an example, the Canberra and Venus models are usually £4500+delivery and VAT, they would be £3600.

The large Heart-shaped birthing pool, which can be stand-alone or fit against an IPS, is nearly £1000 off.

The Dunoon, our budget compact birth bath comes with free delivery, saving you at least £250.

If a refurbished, as new, pool would suit your budget better, we can offer you two York model birth baths for the price of one.

As celebrities like Holly Willoughby raise awareness of the benefits of a water birth, you may well find you have more women wondering if it’s for them. With our offers making it easier than ever, we’d love to see more women able to get the pools they want.

Contact Ruth or David 0345 230 1381

www.aquabirths.co.uk

Offer ends 1st March 2015.