ACM’s updated position on use of water in labour

Opening statement

The Australian College of Midwives (ACM) has assessed the current evidence in relation to the safety of access to water immersion during labour and birth. Having reviewed the available evidence, it is ACM’s position that the current evidence does not support discontinuing the use of water in labour or of water immersion. This is especially true if the laboring woman is not suspected or confirmed as having contracted COVID-19.

ACM appreciates the situation in COVID-19 hotspot areas is confronting, and recognises the desire to prioritise the safety of health care workers. However, we encourage hospitals to act in accordance with clinical evidence.

ACM notes that our position is aligned to that of the United Kingdom’s Royal College of Midwives (RCM) as outlined in their Clinical Briefing Sheet – Waterbirth during the COVID-19 pandemic (29-July-2020) which recommends that “current evidence does not suggest that there should be a blanket cessation on the use of water in labour or waterbirth for all women.” The RCM Clinical Briefing Sheet can be accessed at the following link:

www.evidence.nhs.uk/search?om=[%7B%22srn%22:[%22Royal%20College%20of%20Midwives%20-%20RCM%22]%7D]&q=water+birth&sp=on.

Water immersion for labour and birth during the COVID-19 pandemic

The COVID-19 pandemic has elicited changes to the provision of maternity care around the country. Directives and policies have been initiated with recognition of the significant risks associated with the virus and the devastating outcomes that have been seen across Australia and the world. ACM supports the implementation of evidence-based practice to safeguard as much as possible, the health and wellbeing of both women and their babies but also midwives, obstetricians and other health care workers who are providing care.

The rapid and dynamic changes in directives, while necessary in light of the evolving situation, have resulted in women experiencing heightened uncertainty, anxiety and fear. Women have expressed frustration with policies and recommendations that have limited their ability to exercise choice, especially those that have limited support people and impacted on their birth preferences (1). Concerns have been raised about the short and long-term impacts of such decisions on women’s mental wellbeing.

ACM supports a woman’s right to exercise informed choice about all aspects of their pregnancy, childbearing and transition to parenthood, with this including the use of pain reducing strategies beyond the available pharmacological methods. This includes the use of water immersion during labour and birth.

We have recently become aware of recommendations surrounding the use of water immersion for labour and birth in response to the COVID-19 pandemic. More specifically, we hold concerns about a recent recommendation that advises that the use of water immersion for labour and birth be suspended for all women in areas of high community transmission and in particular, the suggestion that the practice presents an ‘unacceptable risk.’

Immersion in warm water provides women with much more than pain relief; research demonstrates that women feel a greater sense of safety, privacy, control and self-determination when immersed in a bath of water (2-4). The pool provides a physical barrier between the woman and her environment with this facilitating a sense of protection, both from distractions and interventions and the creation of a personal space leading to ease of movement and synergy between mind and body (2, 5). The benefits are well-documented. While concerns surrounding the safety of water immersion have been raised, research consistently demonstrates that there is no increased risk when compared with labour and birth out of water (6-8).

While we acknowledge and support the recommendations that have been implemented to slow and stop the spread of COVID-19, we continue to hold that women who choose to labour and/or birth in water are supported to do so, where there are no known contraindications. ACM has not found evidence that warm water immersion poses an ‘unacceptable risk’ to clinical staff, women and/or their babies but instead, an effective option for not only supporting women to achieve a normal, physiological birth but also for facilitating a positive and satisfying birth experience. Furthermore, this decision seems out-of-step with a further recommendation relating to the use of nitrous oxide. Despite the potential for aerosolisation as a result of nitrous oxide use, a ‘cautious approach’ is advised for women with suspected COVID-19 and usual practice for those at low-risk of COVID-19.

In light of the paucity of research to suggest that warm water immersion during labour and/or birth presents additional risks to well women and their babies in an area of high community transmission or indeed, any other setting, we implore those who have suspended the practice to reinstate access as a matter of urgency.

COVID-19 and water immersion: key points

·      COVID-19 is not a waterborne virus; it is transmitted through air via droplets (due to coughing, sneezing, breathing) or from surfaces that may be contaminated by said droplets; as such, the act of immersing in warm water during labour and/or birth is not likely to increase the risk of transmission, instead it may actually reduce the risk of transmission.

·      A watery environment dilutes any potential risk of respiratory droplet and/or faecal contamination (NOTE: Testing of faecal samples has been conducted in water due to the reduced risk of droplet and aerosol contamination (9)).

·      While COVID-19 may be found in faeces, there is currently no evidence of faecal-oral transmission (10).

·      Acknowledging that faecal contamination has been raised as a concern, it is important to note that the water has the effect of diluting virus particles that may be present providing some level of protection against transmission particularly when compared with land birth.

·      The physical barrier offered by the bath/pool assists with social distancing between the woman and those who are present for labour and/or birth including midwives and support people.

·      Women who give birth in water commonly receive their baby and gently guide their baby to the surface thereby reducing contact between the woman (and baby) and midwives (unless, of course, there is a need to intervene).

·      Adherence to birth pool cleaning protocols further reduces if not eliminates the risk of transmission to subsequent users.

·      Midwives have ready access to personal protective equipment (PPE).

References

1.       Cooper M, King R. Women's experiences of maternity care during the height of the COVID-19 pandemic in Australia. Canberra: Australian College of Midwives; 2020.

2.       Ulfsdottir H, Saltvedt S, Ekborn M, Georgsson S. Like an empowering micro-home: a qualitative study of women's experience of giving birth in water. Midwifery. 2018;67:26-31.

3.       Cooper M, Warland J. What are the benefits? Are they concerned? Women's experiences of water immersion for labor and birth. Midwifery. 2019;79:102541.

4.       Fair CD, Crawford A, Houpt B, Latham V. “After having a waterbirth, I feel like it's the only way people should deliver babies”: The decision making process of women who plan a waterbirth. Midwifery. 2020;82:102622.

5.       Carlsson T, Ulfsdottir H. Waterbirth in low‐risk pregnancy: An exploration of women’s experiences. Journal of Advanced Nursing. 2020;76(5):1221-31.

6.       Neiman E, Austin E, Tan A, Anderson CM, Chipps E. Outcomes of waterbirth in a US hospital‐based midwifery practice: a retrospective cohort study of water immersion during labor and birth. Journal of Midwifery & Women's Health. 2020;65(2):216-23.

7.       Snapp C, Stapleton SR, Wright J, Niemczyk NA, Jolles D. The Experience of Land and Water Birth Within the American Association of Birth Centers Perinatal Data Registry, 2012-2017. The Journal of Perinatal & Neonatal Nursing. 2020;34(1):16-26.

8.       Hodgson ZG, Comfort LR, Albert AA. Water Birth and Perinatal Outcomes in British Columbia: A Retrospective Cohort Study. Journal of Obstetrics and Gynaecology Canada. 2020;42(2):150-5.

9.       Wang W, Xu Y, Gao R, Lu R, Han K, Wu G, et al. Detection of SARS-CoV-2 in different types of clinical specimens. Jama. 2020;323(18):1843-4.

10.     World Health Organisation (WHO). Water, sanitation, hygiene and waste management for the COVID-19 virus Technical brief 3 March 2020 2020 [Available from: https://apps.who.int/iris/bitstream/handle/10665/331305/WHO-2019-NcOV-IPC_WASH-2020.1-eng.pdf.