Obstacles to a Waterbirth
Often mothers looking to have a waterbirth are faced with resistance from the medical profession because they present so called "high-risk" conditions such as pre-eclampsia or epilepsy, or are expecting twins. Here we provide some guidance as to what to expect, what to do and where you can find support or additional information.
Overcoming Obstacles: hospital Policy
Waterbirth and Pre Eclampsia or High Blood Pressure
Waterbirth and Epilepsy
Waterbirth and Preterm Labour and Birth
Waterbirth and Post Term Inducement
Waterbirth and Ceasarean Section
Waterbirth and Group B Strep
Waterbirth and Malpresentation
Waterbirth and Multiple Birth
Waterbirth and Being "Overweight"
Most research on waterbirth focuses in what is generally referred to as low-risk pregnancies. As a result, hospitals or birth caregivers are free to set their own policies regarding waterbirth and what they consider to be high-risk pregnancies. Because very little research has been undertaken on the use of waterbirth in high risk pregnancies, be aware that policies are often based on opinions rather than facts. We have listed below some of the most common "high-risk" pregnancy circumstances that could be seen by many health professionals as contraindications to a waterbirth. In each case, we provide some guidance as to what to expect. However, if your pregnancy is considered high risk, never ignore the opinion and advice you receive from your attending midwife on the day of your birth.
Overcoming Obstacles: Hospital Policy
The greatest obstacle to a water birth may be your hospitals attitude to it. If your pregnancy is considered high risk you might fall outside of your hospital's waterbirth policy. If you meet with opposition you have the right to a second opinion which may be from another hospital, from an an independent midwife or from a private consultant obstetrician. Organisations such as the NCT and AIMS often have volunteers who have birthed in special circumstances and are willing to share their experiences. The UKmidwifery email support group has a wealth of midwifery and user experience which you can access free of charge. The Association of Radical Midwives also offers a helpline staffed by an experienced independent midwife. The NCT have a Pregnancy and Birth Line run by qualified antenatal teachers - call 0300 330 0700 in the UK to access this. Getting good quality information and support is very important, especially if you are looking to challenge the policy of your maternity unit.
Opposition to your water birth plans may be based on lack of knowledge, training or experience rather than on concrete evidence about your "high risk" condition.
Waterbirth and Pre-Eclampsia or High Blood Pressure
labour and birth and this is potentially fatal to mother and baby. Careful monitoring of mothers in pregnancy to find those who are in danger has brought about a drop in maternal and fetal mortality in the last century. It is worth putting it into context though, the Pre-Eclampsia site states that Eclampsia affects about 400 women per year in the UK. The symptoms of pre-eclampsia: high blood pressure, protein in mother's urine are identifiable during routine antenatal checks.
If you have been diagnosed with pre-eclampsia you may be able to use water during the early stages of labour but will be asked to exit the pool to give birth as this is believed to raise the blood pressure further and may make it more likely that you will develop eclampsia. If you have severe pre-eclampsia then it can be difficult to monitor you effectively in a birth pool. However, in some units the fear of pre-eclampsia and its complications has led to rather rigid rules around what is a "safe" level of blood pressure rather than treating women as individuals. What is a high reading for one woman might be normal for another - knowing what is normal for you in pre-pregnancy or using previous pregnancies as your guide might be helpful in negotiating over your care.
There are studies showing that using water in labour can lower blood pressure in many women so it might be possible to negotiate using a pool if you are willing to have your blood pressure monitored regularly. High blood pressure alone, without other signs of pre-eclampsia is very common in pregnancy, about 10% of women will experience this and it is important to determine whether you are truly at risk or are being denied your birth choices due to a rigid hospital policy. Many midwives have noted that women who are about to go into labour will have a spike in their blood pressure - having your birth choices dictated by one blood pressure reading may be a little draconian and you may prefer to negotiate on a wait and see plan and action rather than being put straight onto consultant led, hospital based care with no birthing pool.
Waterbirth and Epilepsy
Women with epilepsy are sometimes told they cannot use water to give birth. This does not seem to be an evidence based policy and some units will "allow" the use of a pool if you have not had a seizure for a year or more.
Waterbirth and Preterm Labour and Birth
Premature babies need close monitoring and may need support with breathing after birth so the use of a water birth pool is not a good idea. However, there is an issue around defining "pre-term". Despite the World Health Organisation defining normal term as between 37-42 weeks, some maternity units still refuse access to a pool if a pregnancy is less than 38 weeks. By contrast, many independent midwives are very relaxed around supporting women to homebirth in water at 37 weeks. You might like to negotiate around using the pool for labour if not the birth itself if you are birthing in hospital. At home it would be very difficult for a midwife to prevent you from birthing in water.
Waterbirth and Post-termPregnancy
It is increasingly common for maternity units to have a policy of "offering" induction at about 10 days past 40 weeks of pregnancy. In some maternity units this is translated into an intense pressure to conform to policy and is not presented as a choice at all. You should be aware that this is only an offer and you are never obliged to accept that offer. The evidence for this is very out of date and NICE have recommended that more research needs to be done. There is certainly evidence to show that first time mothers have an average pregnancy duration of 41 weeks and 1 day so this is a very common problem that parents to be having to face. You are also more likely to go "overdue" if you have a menstrual cycle of over 28 days. You have the right to decline induction and opt for "expectant management" which means increased monitoring of you and the baby with an extra scan if you wish it. Units may say that they do not support home birth after 42 weeks but legally a midwife cannot refuse to attend you in labour.
Accepting induction means a hospital birth. The recently revised NICE guidelines on Induction say that use of a birthing pool is recommended in an induced labour but it is important to look at the likelihood of induction being successful in starting off labour. If induction with prostaglandin pessary does not get you into labour then an oxytocin drip is needed and this causes contractions which can be very painful, sudden in onset and which can cause fetal distress so continuous electronic monitoring is necessary - this cannot be done in a birthing pool. Often women use an epidural if they are having an oxytocin drip. You need to be clear that if you accept induction it may limit your birth choices and may well lead to more intervention than you had planned.
It is a good idea to be clear about the evidence on being overdue. AIMS produce a very good booklet calledInduction: Do I Really Need It? and this may help you decide whether this is a good, evidenced based decision for you and your baby.
Waterbirth and Caesarean Section
Women who have had a previous caesarean birth are considered very high risk in their subsequent pregnancies. Most are told that they cannot use a water pool. Instead they are told they must birth on a consultant led unit, have a needle for a drip inserted on admission in case they "collapse", be continuously monitor in case their scar ruptures and must birth within strict time limits. Given those constraints it is not surprising how low the vaginal birth after caesarean (VBAC) rate can be in some hospitals. Yet vaginal birth is recommended as safer than repeat caesarean by most evidence based policies and the evidence for all these precautions is very slender. It presupposes a high risk of uterine rupture, yet the actual figures for uterine rupture in a woman who has had a previous caesarean are very low indeed.
More and more women are choosing to home and water birth rather than fight over rigid hospital policies although some successfully negotiate use of a water pool and midwifery led care. Much seems to depend on the attitude of the individual obstetrician. There are a number of support groups available online, details of which are available on www.caesarean.org.uk. AIMS have a useful book Birth After Caesarean and the NCT have Caesarean and VBAC support co-ordinators who are happy to talk to mothers about their choices.
Waterbirth and Group B Strep
It is thought that about 30% of women in the UK are carriers of Group B Strep (Source: Group B Strep Support). For most this is no problem at all. Half of all women colonised with GBS will pass it on to their babies, less than 1% of those babies will develop an infection and for most of those it will not be life threatening yet for a very few it will be fatal. Routine testing is not done in this country because it is very inaccurate and because just identifying Group B Strep isn't always helpful. Giving antibiotics routinely to babies whose mothers have GBS causes more problems with adverse reactions to the antibiotics than it solves with the GBS.
New NICE guidelines have helped women wanting water birth with a diagnosis of Group B Strep and if your unit is not following this guidance it is worth printing it off from the NICE website www.nice.org.uk and asking by letter why they are not following it. Home water birth can still be more problematic however routine antibiotics for women with no other risk factors is no longer recommended and, in any event, some women have managed to have antibiotics administered in hospital and then return home to birth or have successfully negotiated taking oral or injected antibiotics or even had an IV drip whilst in the pool.
For more information on Group B Strep, AIMS and the Association of Radical Midwives have good, evidence based and anecdotal information.
Waterbirth and Malpresentation
If your baby is in a breech (bottom or feet first) position at 35 weeks of pregnancy, most maternity units will tell you that you must have a caesarean section. Curiously they will put this in their figures as an "elective" caesarean despite having given you little say in the matter. Some will first offer manual turning of the baby, called external cephalic version which research has shown to be safe and quite successful if done by an experienced obstetrician, having first done ultrasound and with an operating theatre facility close at hand. If the baby doesn't turn then a caesarean is usually schedules for 38-39 weeks of your pregnancy. The decision to offer caesarean has been based on very poor evidence, the most recent of which the Term Breech Trial has been widely derided in midwifery circles for its inaccuracy and the final 2 year follow up of that trial showed no difference in outcome between caesarean and vaginally born babies. Still the NHS continues to recommend elective caesarean and is failing to train midwives in how to birth breech babies vaginally.
The independent midwife, Mary Cronk and her colleague Jane Evans have been running study days around the country for midwives to retrain to birth breech babies safely, although we note that Mary is clear that not all breech babies can or should be born vaginally. See Mary Cronk's excellent article on breech presentation. You do have the right to refuse a caesarean and to insist that your hospital provide you with appropriately trained midwives. Some women have succesfully negotiated that their NHS trust pays for an independent midwife to birth the baby where their own midwives consider themselves untrained. AIMS have a book on breech birth and there is very good information on breech at the Association of Radical Midwives website. Not all breech or transverse babies can or should be birthed vaginally. Taking advice from an experienced midwife is very important.
Back to Back or posterior babies are increasingly being viewed as malpositioned. There are theories that our more relaxed lifestyle and lack of physical movement, our reclining chairs and bucket car seats are leading more babies to lie with their backs against mothers spines and causing longer labours which are more likely to lead to interventions such as caesarean. Jean Sutton is a leading proponent of this theory and she has exercises which she suggests to help turn babies to the anterior position in pregnancy or, if that doesn't work, in early labour. Some chiropractors believe that misalignment of the woman's pelvis can cause posterior babies and that they can treat this even in late pregnancy.
Some midwives however believe that posterior is simply a position that some babies adopt and by adopting upright, forward leaning positions and not intervening too soon, many woman can still birth her baby with no problems. Using a birthing pool is ideal in a posterior labour as it helps to ease back pain and helps the woman to use the best positions to encourage her baby to turn. There should be no obstacle to using a birth pool just because the baby is in a posterior lie.
Waterbirth and Twins or More
Women expecting twins are often told that they have to: have a hospital birth, accept routine induction at 38 weeks, and be routinely monitored throughout labour . Most hospitals will tell twins mums they are definitely not candidates for a water birth. As with breech birth this management of labour is being increasingly challenged by those women who have taken time to inform themselves about the issues and the evidence. The Association of Radical Midwives website has birth experiences and midwives viewpoints on home and water birth with twins. Mary Cronk's twin guidelines are a real eye-opener to anyone who has been presented with a standard consultant view of twin birth. AIMS has a very helpful booklet on twin birth and their former newsletter editor Emma Mahoney has written a book called Double Trouble which you may find helpful. It can be hard to find books which treat twin pregnancy and labour in a positive way. Elizabeth Noble's book Having Twins has some very helpful information too, written from an American perspective.
Waterbirth and Obesity
Being of larger build in our society is a big social issue and increasingly the medical profession is seeing it as a problem in pregnancy and birth. Most hospitals now have a policy of not "allowing" water birth where women have a pre-pregnancy Body Mass Index (BMI) of over 35. Whilst there is evidence to show that obese women are more likely to have high blood pressure, pre-eclampsia or developing diabetes this is another case where women are in danger of having choices restricted by one policy fits all. Many midwives believe that an obese women with normal (for her) blood pressure, no signs of pre-eclampsia and who is not diabetic should be treated less as a walking time bomb and more as an individual whose needs should be individually assessed and should not be arbitrarily barred from using the best non-invasive pain relief for labour. More information and support can be found at the Plus Size Pregnancy website. Obese women who feel judged or criticised by their carers may feel inhibited during the birth and may need to think carefully about who they allow at their birth and ensure they have positive supporters who protect their privacy and sense of self worth.