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.
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
By far, the greatest obstacle to a waterbirth will be your hospital’s attitude towards it. If your pregnancy is considered high risk, you might fall out of your hospital’s waterbirth policies. When meeting with opposition, whatever the reason, always ask for the research on which this is based, and if necessary, seek a second opinion either from another hospital or an independent midwife. Organisations such as the NCT and AIMS often have volunteers who have birthed in special circumstances who are willing to share their experience. The UKmidwifery Yahoo Egroup (email support group) has a wealth of midwifery experience which you can access. Getting support and good quality information is very important, particularly if you are implicitly challenging set policies at your maternity unit.
Often, outright opposition to a waterbirth due to high risk factors are not based on evidence but rather on lack of training, knowledge or experience. This is what you have to find out. If you are expecting twins for example, a waterbirth will be usually discouraged. Yet there are many examples of twin births in water to show that this is possible. If however, your chosen midwife or carer does not feel confident in her ability to deal with this, you should respect her limitations and perhaps look for someone else to care for you. Remember that "a fearful attendant may translate into a fearful mother and a stalled labour".
Waterbirth is still a relatively new practice and one that requires a lot more research. Until then, overcoming the stigma and its related policies will remain a major obstacle to waterbirth.
Waterbirth and Pre-Eclampsia or High Blood Pressure
Pre-eclampsia is a serious condition insofar as it can evolve into eclampsia during labour and birth. However, according to the Pre-eclampsia site this "is rare and affects about 400 women per year in the UK". The symptoms of pre-eclampsia, high blood pressure and evidence of proteins in the mother’s urine, are easily identified during routine ante-natal 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. If you have severe pre-eclampsia, then the need for close monitoring of both you and your baby makes the use of a pool difficult. In some units, the fear of pre-eclampsia has been translated into rigid guidelines as to what a "safe" level of blood pressure is. Blood pressure however is relative to every woman and these rigid rules might unnecessarily bar you from using the pain relief that you need. Sometimes health professionals forget that one of the benefits of using water is increased relaxation and lowered blood pressure. You may be able to suggest using water and having your blood pressure monitored periodically while you are in the pool. It will be no surprise that your blood pressure may actually be better in the water than out!
Waterbirth and Epilepsy
Women with epilepsy are sometimes told they cannot use water to give birth. This, however, doesn’t seem to be based on any evidence 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 will need closer monitoring and may need support with breathing after birth, so the use of the pool is probably not a good idea. The issue becomes defining what "premature" means. Despite the World Health Organisation specifying 37 to 42 weeks as being normal term, and most midwives agreeing with this, some maternity units still decline access to the pool if a birth is less than 38 weeks. Equally some independent midwives support women who birth at home in water at 36 weeks. In this situation, you could still arguably safely use the pool for labour, if not the birth.
It is worth looking at the evidence on "post maturity", being overdue, as there is a lot of pressure on women to be induced before 42 weeks effectively ruling them out of any home birth plans. This can severely impact water birth plans. Most units will "allow" a woman who has had induction using prostaglandin gel to labour in a birth pool once labour is established, providing that the baby’s heartbeat shows no adverse signs. However, if an oxytocic drug is being administered, the baby and mother need to be monitored quite closely, the use of a pool is unadvisable. If induction is being suggested to you, either for "being overdue" or for any other reason, then it is important that you understand the specific reason why this is a good idea for you or your baby rather than feeling compelled to comply with one catch-all policy. AIMS produce a very good booklet called Induction: Do I Really Need It?
Almost all women who have had a previous caesarean will be told that they cannot use a water pool, cannot birth in water or even use a pool for pain relief, must have a needle for a drip inserted at the start of labour, must birth within certain time limits and must have continuous electronic foetal monitoring throughout labour. The evidence for all of this is very slender. It presupposes a high risk for uterine rupture and yet the actual figures for uterine rupture in a woman who has had a previous caesarean (or two, or three or more) are very low indeed. AIMS’ Birth After Caesarean is one of the only books on the market if you are thinking of what is often referred to as VBAC (Vaginal Birth After Caesarean). More and more women, faced with rigid rules which seem unlikely to help them to labour normally, are negotiating the use of a birth pool with their maternity unit or opting for a home birth and using a pool there. There are a number of support groups available online like the UKVBACHBAC group. Another good resource is Caesarean.org, and the NCT have Caesarean and VBAC support co-ordinators who are happy to talk to individual mothers about their choices and feelings.
Group B Streptococcus (GBS) is a difficult issue when it comes to home and water birth. According to the Group B Strep Support, some 30% of women in the UK carry GBS in their intestines without symptoms. Most have their babies without any problems at all. As routine testing is very inaccurate, it is not done in this country. You might be tested if, for example, you reported vaginal discharges.
GBS infection, which happens in a few cases when the baby is exposed to GBS during a vaginal birth, can potentially be disastrous to your newborn. In particular if your baby is premature, if you have a high temperature during labour, or if you have been in labour for more than 18 hours after your waters had broken, if you have a urine infection or if you have had a previous child infected, then may be offered antibiotics when you go into labour or your waters break. In most cases this must be done via a drip but it could also be given intravenously in one dose. Other than for premature babies, this does not rule out a home birth, as your midwife should be able to administer this at home. If your baby does not fall into the higher risk category, the issue of intravenous antibiotics in labour is less clear cut. The Royal College of Obstetricians and Gynaecologists only advise that it should be "considered". As always, if it is your maternity unit’s policy, it is up to you whether you wish to follow it or not and you should be advised by your unit of the risks of intravenous antibiotics to mother and baby when making your decision.
In the context of a home or water birth, a breech birth is another difficult issue. Currently most maternity units will routinely elect you for a c-section should your baby present breech. This means that, despite considerable disagreement as to the need for a caesarean, midwives have had very little experience in helping mothers birthing their breech babies. But according to Mary Cronk, MBE, in her article Midwifery Skills needed for a Breech Birth: “A normal labour and a spontaneous birth are not to be excluded just because the presenting part is the breech”. She does go on to state that not all breeches can or should be born vaginally.
It is clear however that, if you were faced with the prospect of going through a breech birth without an experienced carer then you might opt for a caesarean. You should discuss with your midwife or carer what to do if your baby is breech. Depending on the experience of the midwife you could be able to give birth at home or even in water. Breech Birth? What are my options by AIMS is a very good source of information or read the section on breech birth at the Association of Radical Midwives site (also see their Breech and Home Birth and their Breech and Caesarean Section sections).
Twin birth is another issue where many women are told they have to hospital birth, accept routine induction at 38 weeks, "must" be monitored throughout labour and not use a birth pool. As with breech birth this kind of practice is being increasingly rejected by women who have taken time to inform themselves about the issues and the evidence. As can be seen from some experiences posted on the Association of Radical Midwives website, a home birth or a waterbirth should not be precluded off hand. AIMS has helpful publications about Twins, and their former newsletter editor, Emma Mahoney, has written a book called Double Trouble about her experiences. Elizabeth Noble’s Having Twins also gives useful information on twin pregnancy, birth and beyond.
Being of larger stature in our society is a big issue, and some hospitals have made it a bigger one by having weight limits on who can use their birth pools. This is often presented as a health and safety issue. At first glance, these policies may seem to be sensible given that in the unlikely event of a woman "collapsing" in the birth pool, it might be difficult for the midwives to get her out. However, a woman "collapsing" anywhere is likely to be a problem and we are not aware of any larger framed women being told they cannot use a bath in hospital. More information can be found at the Plus Size Pregnancy website where you can read BBW Birth Stories of home and waterbirth.