Is Waterbirth Safe? Important article from mid 1990s.

From MIDIRS 1994
(hastily pasted in - may look a bit odd)
Is water birth safe?The facts behind the controversy.The dust is beginning to settle after the press publicity which linked somebaby deaths with the use of water in labour. Now is the time to examine thefacts and determine whether there is serious cause for concern. Jily Rosser,editor of MIDIRS Midwjftry Digest, investigates~The Bristol babiesWhat actually happened at the water births at the centre of all thecontroversy? Most of the media attention focused on St Michael's Hospital inBristol, where there were two bad outcomes (a perinatal death and braindamage) to babies born to women who laboured in water. A letter to theLancet' (written by obstetricians, paediatricians, but no midwives) raisedthe possibility that the temperature of the water may have led to'significant fetal cerebral vasodilation.... Theoretically this couldcritically compromise a susceptible fetus.'In the case of the baby who died shortly after delivery the mother, a 29year old primigravida, was in the water for two and a half hours. Thetemperature of the water was kept 'at a comfortable level.' Being booked fora domino delivery, she received care from her community midwife. Toward theend of the first stage of labour she left the water on the advice of themidwife, who had picked up a late deceleration in the baby's heart rate. Shemoved to a conventional labour room on the delivery suite and a CTG wasattached to her. A short CTG was obtained, by which time delivery wasimminent. Subsequently an apparently normal baby was delivered in poorcondition and it died 15 hours after birth. The post mortem showed no causefor the asphyxia, and at the time no connection was niade with the mother'simmersion in warm water during labour. The bereaved mother does not believethat water had anything to do with her baby's death.In fact, the notion was only raised when a second baby was born in poorcondition following the use of the pool. In the Lancet letter it states thatthe temperature of the water was just under 39.7°C when the woman enteredthe pool, but does not mention that the midwife soon noticed and cooled itimmediately to just under 37°C. Thus the woman was not exposed to water anyhotter, or for any longer, than she and all other pregnant wonien wouldexperience in the course of having a bath in the normal way at home. Thewoman was using the water for pain relief and did not intend to deliver inthe pool. Clear liquor was draining. Towards the end of the first stage thebaseline was raised to 160 bpm and the midwife picked up a deceleration withthe hand-held Doppler.The woman was advised to leave the pool, because 'women are asked to conicout of the water if we are at all worried about them'2 moved to the labourward, and a VE fifteen minutes later found her cervix to be fully dilated.During the second stage further decelerations were noted and a baby boy wasborn in poor condition. As with the first case, resuscitation was prompt anduncornplicated; nevertheless, the baby developed grade three hypoxicischaernic encephalopathy and is brain damaged. He is still too young for aprognosis to be made.This then, is the factual basis of the concern over the use of water inlabour. The impact at St Michael's has been some tightening of the protocolsaround water birth, and a slight reduction in the number of women choosingto deliver under water. But it is to the great credit of the St Michael'smidwives that the protocols around use of water in labour were alreadytight3 and as the senior midwife on labour ward points out, they work:the only two babies with whom they had difficulty did not deliver underwater, but were asked to leave the pool in good time.ProtocolsPrior to offering the pool room to clients the midwives had gathered as muchinformation as they could. In the absence of evidence from clinical inalsthey devised very cautious guidelines based on the experience of others.They were acutely aware that, as a woman and midwife led innovation, waterbirths were particularly vulnerable to criticism from the medicalestablishment. There was also a strong sense of responsibility that allpatterns of care should be rigorously evaluated.4 To this end, detailedstatistics are kept on all the women using water in labour, and this carefulapproach has enabled the St Michael's midwives and the birth pool, toweather the stonm The only changes made in the protocols were:4 MIDIRS Midwifery Digest (Mar 1994)4:1I. that the water be kept cooler than before until delivery is imminent(34-35°C in first stage, 37-38°C in second stage)2. the woman is asked to leave the pool if her temperature is raised oreither her or the baby develop tachycardia3. she is asked to leave the pooi every three hours for a short CTG traceThe irony of this last recommendation (that is as little based on researchas water birth) is not lost on the midwives.The St Michael's midwives clearly believe that there is no evidence that,because the women laboured in warm water there were poor outcomes for thebaby. So why was the reaction of the medical profession so strong? It istempting to interpret their reaction in terms of control. The use of waterin labour is outside their province; at St Michael's no obstetrician hasever been called in to the birth pool room2. It is possible that thediscomfiture that many doctors feel is placated by their insisting onpseudo-scientific protocols which can at least be quantified and recorded.Many must feel considerable relief at having negotiated an electronic fetalheart monitor into the birth pooi room, even though it is illogical of seekto make one unevaluated intervention safer by insisting it is monitored by asecond unevaluated intervention.Birth underwaterSo much for labouring in water, what of giving birth underwater? Again, thefacts must first be described. Historically, one well known case is that ofthe baby who died in the Dordognes region of France in the late 1 980s. Infact, this baby was not born underwater but, at an unattended home birth wasborn in the membranes~. The parents were unable to deal with the situationand the baby drowned in its own amniotic fluid. More recently, in mid 1992in Vienna, Austria, a baby was severely brain damaged following a waterbirth at home. This birth was also unattended: when the midwife arrived some25~30 minutes after the birth she found the baby still underwater, with theparents standing out of the pool and watching it sucking its thumb.6 Inneither of these cases was water the issue; lack of a trained attendant was.But while scrutiny of the facts is reassuring in all the above cases, in themost recent case it is not. For in October a baby died following awaterbirth in Stockholm, and there is a real cause for concern. A woman wasgiving birth at home, attended by two experienced midwives. They listened tothe fetal heart after every contraction with a hand-held Doppler and it wasnormal throughout. Shortly before the birth the woman defecated, and thebaby boy was born intocontaminated water. The midwives observed the baby making respiratorymovements as he was being brought to the surface, and he emerged severelyasphyxiated. The midwives were not able to resuscitate the baby with mouthto mouth or bag and mask. Thirty minutes later, in the hospital, thepaediatrieians found the baby initially impossible to ventilate and it wassixty minutes before he started to breathe. The ventilator was switched offafter ten hours. The forensic post mortem 'showed clearly' that the baby hadinhaled water into the lungs7. Professor RagnarTunell, the paediatrician whooversaw the case, has painstakingly pieced together all the elements of thetragedy and his personal belief is that the following occurred. This was oneof the 20% of babies born severely asphyxiated in whonî there are nodetectable problems with the heart rate in labour. The severe asphyxiaoverrode the inhibition to gasping which normally occurs in babies bornunder water, and the baby inhaled into his lungs quantities of highlycontaminated water. Resuscitation was made difficult by the resistance inthe fluid-filled lungs. It would appear that this baby might not have diedhad he been born into air. A second inescapable conclusion is that he mightnot have died had he been born in hospital. Planned underwater births havebeen discontinued in Stockholm.The responseWhat now are we to do with this information? There have been kneejerkreactions both ends of the spectrum. Denial is certainly unhelpful. Thefounder of a pool hiring company sent out a press release saying that in thecase of the Swedish baby 'there is no evidence whatsoever that the babydrowned or died as result of the mother using a water birth pooPY Such illinformed comments do a disservice to her customers. On the other hand wehave the president of the Royal College of Obstetricians and Gynaecologi stsexpressing concern over mammals being born into the unnatural medium ofwater~°. It is difficult to know whether to be pleased that the RCOGrecognises that humans are mammals and that the birth environment shouldsuit our mammalian nature, or to be cynical that the labelMIDIRSMidwifery Digest (Mar 1994)4:15unnatural' is so readily applied to water birth in a pejorative sense, butnever mentioned in connection with, say, induction or epidural. The RCM gavea more measured response but included the worrying advice that 'the babyshould be brought to the surface within one to two minutes of delivery".'The only safe advice is to bring the baby to the surface immediately.It is the comparison with epidural that is the most tempting to explore.Here too is an intervention designed to relieve pain in labour, introducedwithout adequate evaluation of its safety and known to affect coretemperature in labouring women. There must have been, as a statisticalcertainty, unexpected perinatal deaths in apparently healthy babiesfollowing the mothers' use of an epidural in labour. but no letters in theLancet, written by concerned practitioners, followed these.UnethicalSeveral recent articles have been critical of midwives readiness toundertake water births when their safety remains unevaluated.'2'3 But thereis an important distinction between health professionals introducing anintervention of unproven benefit with which women are expected to comply asthey are told it is of benefit to them or, more likely, their baby (eg CTGin normal labour, routine ultrasound scan in pregnancy) and professionalsresponding to client requests for an intervention such as waterbirth. Whileobjective evaluation is equally important in both cases, the first instanceis unethical. The second is not. In fact, midwives who have responded toclient requests for water births have strenuously sought information; in1993 MIDIRS responded to 187 requests for a search on use of water inlabour; over the past several years the total number of searches requestedmust be approaching a thousand.ConclusionAs Sheila Kitzinger, who has been calling for research into water births forover three years, said 'It was so obvious that sooner or later a baby woulddie.' Apparently normal babies do occasionally die unexpectedly. As water isused more often in labour, so the likelihood of a death occurring followingthe use of \vater has risen. The question is, is the relationship a causalone, or coincidental? The balance of evidence to date suggests that the useof water as pain relief in labour is very safe. Many babies have been bornthis way.Associated problems have been very rare, and with none of these has a causalrelationship been cstablished. Careful watch does need to be kept, datacollected methodically and the outcome of the trial currently beingundertaken by the National Peritiatal Epidcmiology Unit is awaited withinterest.Giving birth under water is a more delicate qucstion. Certainly thousands ofbabies have been born underwater without any difficulty. indeed many withgreat benefit. But one has died. And it is likely that he would not havedied if he had been born in air. The reexamination of the events leading upto his death can reveal no other preventable factor. And the contributingfactors (severe birth asphyxia following an apparently normal heart ratethroughout labour, heavy faccal contamination of the water, birth at home)are not rare events. This scenario could be repeated.Midwives are beholden to explore with every client planning to givc birthunder water not only the benefits but the risks, however slight, so that thewoman is able to exercise informed choice. It must then be the woman'sdecision.1. SK Rosevear, R Fox, N Marlow. and others. tweet. Birthing poolsand the fetus (correspondence), vol 342. no 8872.23 Oct 1993. ppI t)48- 1049Ann Tissard, Clinical Midwifery Manager. Delivery Suite, SiM ichael 's Hospital Bristol. Personal communication.3. Footner K. Bristol's new birth pool. MIDIRS Midwifery Digest. vol2,no3,Sep 1992. pp27l-274.4. Ann Remmers. midwifery manager, St Michael's Hospital. Bristol. Personalcommunication. 1994.5. Michel Odent, London. Personal communication. 1993.6. Michael Adam, Obstetrician. Vienna. Personal communication. 1993.7. Ragnar June11, Professor of Paediatries. Stockholm. Persotialcommunication. 1993.8. Ingrey J. [press release]. London: Splashdown Water Birth Services.18th Oct 1993.9. Chamberlain G. Statement on birth underwater. [press release]. London:Royal College of Obstetricians & Gynaccologists. 15th Oct 1993.10. Chamberlain C.Waterbirths [letter to ChiefMedieal Officer] .London:RCOG, 11th Oct 1993.II. Watcrbirth advice. Midwives Chronicle. vol 106, no 1271, l)ee 1993.p474.12. McCandlish R, Renfrew Ni. Immersion in water during labour and birth:the need for evaluation. Birth vol 20 no 2. Jun 1993. pp 79-85.13. Wise J. Waterbirth: trial or error? British.Journal of Midwifery vol I.no 6, Nov/Dec 1993, pp 249-250.Rosser J. MIDIRS Midwifery Digest, vol 4, no 1, Mar 1994, pp 4-6.Original article written for MIDIRS by Jilly Rosser midwifeMIDIRS /994.neterences6 MIDIRS Midwifery Digest (Mar 1994) 4:1Hope this helps. Blames misprints on scanning but better than nothingloveMaragret