The Aspect of Using Water in the First Stage of Labour - Case Study Example

Water Births Introduction The birthing process can be a long and difficult experience for the mother, and consequently for the baby. Various techniques have been used by different cultures and different countries in order to ease this process. The realms of the scientific, the alternative, and the complementary have been explored by various medical practitioners and caregivers in order to the birthing process. The use of water in the first stage of labour and in the actual delivery has been explored as one of these processes. Its effectiveness has been accepted in some circles, and doubted in some others. It has yet to gain widespread acceptance as a complementary and alternative addition to the birthing process. This paper shall explore the aspect of using water in the first stage of labour and in the actual delivery itself. It shall also explore the ethical, legal and professional issues surrounding this process. It shall use current and relevant knowledge about this topic drawn from a range of sources related to the midwifery practice in general. The process The benefit of water births have been an accidental discovery when, in the 1800s, a French woman who was exhausted after 48 hours of labour, climbed into warm bath to relax and subsequently gave birth to her child in the water (Church, 1989, as cited in Pairman, et.al., 2006, p. 430). Such method of birthing was rarely explored and discussed in the next 150 years until Igor Tzarkovsky expressed and renewed interest in this method. In the 1970s, other enthusiasts expressed their support for water births when they called attention to how water births helped to heal and bring peace, quiet, and gentleness to the baby during delivery. Practitioners also noted how women were more relaxed in the water during their labour and their delivery. The interest in this method of birthing gained momentum in the 1980s as more women explored and opted for this method during their deliveries. Many medical centres, hospitals, and practitioners have now set up operations for this method of birthing (Pairman, et.al., 2006, pp 430-431). Midwives, nurses, and obstetricians have also come to integrate this method into their practice. And midwives, most especially, are often being called in to pregnant women’s homes in order to assist patients undertake this method of birthing. Water birth is basically the process of giving birth in a tub of warm water (American Pregnancy Association, 2007). In some instances, women choose to labour in the water and to get out of the water once they are ready to deliver. Other women choose to undertake the entire labour and birthing process in the water. Water births are undertaken under the premise that the baby has been surrounded by water all throughout his nine months inside the womb and it would be henceforth more relaxing for him to be born in a watery environment. Advocates also claim that water births are more relaxing, less stressful, and less painful for the mothers (American Pregnancy Association, 2009). During this process, the mother is assisted by midwives or any other qualified medical professional trained in such types of births. Some experts term this type of delivery as hydrotherapy. Hydrotherapy refers to the use of water to ease the discomforts of labour. This may mean the use of a tub during labour or showering the belly and the back with warm water during active labour. Hydrotherapy allows the woman to stay alert because there are no medical and drug interventions used in this type of delivery. The woman also becomes less anxious in the water. However, in order to be effective, experts recommend that the water should be based on body temperature (about 98.6 degrees Fahrenheit) (Murray, et.al., 2005, p. 399). And this drug-free method of birthing is now actively being used by women as an alternative means of giving birth. Experts cannot deny that water benefits pregnant women and many of them have now come to embrace and advocate this method as a safe option during deliveries. Many experts believe that the benefits of water births are mainly credited to a perceived decrease in pain; however whether or not water actually reduces pain has not been definitively proven. But undeniably, the perception of relaxation, pain relief and ease of movements has made this method an acceptable and welcome choice for many pregnant mothers. The Royal College of Midwives and the Royal College of Obstetricians have come to widely support this method of birthing, but they emphasize the need for attendants with appropriate skills and confidence in water births to be present during these deliveries (Alfirevic & Gould, 2006, p. 1). The process of labouring in water is however a separate matter from delivering in water. Labouring in water can bring about less painful contractions, decreased need for pharmacological interventions, and shorter labour period. Some studies have shown that there is no significant difference in women using water births and those who have chosen conventional birthing techniques in terms of the use of analgesics, the length of labour, operative delivery, perineal trauma, neonatal outcomes, and neonatal infection. However, experts emphasize that many women find the birthing experience easier when water is used during the first stage of labour and during the delivery itself. These experts are quick to caution that water births should only be used in instances of healthy women with uncomplicated pregnancies during term (Alfirevic & Gould, 2006, pp. 1-2). This method of birthing is not recommended to all women because individual characteristics may call for more conventional methods of delivery. Risks of complications in some women and babies can be increased with the use of this method, hence, experts recommend adequate assessment of risks for both mother and child before options can be considered. Ethical considerations There are various ethical considerations surrounding the use of water in the first stage of labour. First and foremost, “considerable pressure can be exerted on midwives if they are not proficient to conduct a water birth and a client is requesting one” (Wilson & Symon, 2002, p. 76). Some patients tend to assume that all midwives are qualified to assist in water births. And sometimes, when the midwife and the patient have known each other for quite some time, the former is pressured to provide water births even if she is not familiar with the method. Many midwives are reluctant to admit to their clients that they have no knowledge or expertise in water births. It is imperative for midwives to make clear to the patients the extent of their expertise and knowledge in water births. Practitioners also recommend that midwives who are in this dilemma should call on another colleague who is trained in water births and she can assist during the procedure. Such opportunity will keep the mother and the baby safe and give the midwife a chance to learn from the experience (Wilson & Symon, 2006, p. 76). Another consideration in this regard is when the midwife is the only member of the health care team who has the expertise in this type of birthing, and she does not wish to cover the delivery on a 24-hour on-call basis (Wilson & Symon, 2002, p. 76). The midwife is placed in a dilemma of making herself available 24 hours a day to the patient at great detriment to her health and her physical stamina. However, when the midwife is the only member of the health care team who is an expert in the field, shouldn’t she be relied on 24 hours a day in order to ensure the success of the procedure? The answer is no. The midwife cannot successfully function as a member of the health care team if she is overworked and stressed out with her work. At some point, the other members of the healthcare team have to assist and do their part in order to ensure that the midwife is physically and psychologically prepared for the procedure. However, it is important for the midwife to express her preferences to the other members of the health care team. She cannot deliberately make herself unavailable to the other members just because she does not feel like being on-call for 24 hours a day. “In order to manage the clinical risk, midwives and supervisors need to work together to resolve the issues, meeting the client’s and the midwife’s needs” (Wilson & Symon, 2006, p. 76). The supervisor may also call on a team of other midwives who are trained in water births to help care for the woman before her delivery so that the midwife familiar to her can attend to her during her actual delivery. This remedy can ensure that the patient is attended to at all times by a team of midwives trained in water births. At any time she is ready to give birth, the midwife of her choice will be physically and psychologically ready to care for her needs. Another ethical consideration in the use of water during the first stage of labour is about the temperature of the water of the birthing pool or tub. There are different standards set by different experts and institutions on the matter. A Swedish study was able to give the best advice on this matter by recommending a range of temperatures from 34 to 37 degrees Celsius depending on the woman’s preference. The study recommends that it is best for the woman to regulate and choose the temperature she is most comfortable with during her labour (Alfirevic & Gould, 2006, pp. 3-5). Considering the wide range of temperature and the possible choices of the woman, it is actually difficult to strictly enforce regulations to the woman in this regard. If the midwives knowledge of the matter requires for a certain temperature to be followed, she should consider carefully such regulations and standards in order to achieve the best result for the patient. The main ethical consideration in the matter of water births is the fact that, although it has been proven to benefit the mother, studies reveal that it does not benefit the baby. The baby is exposed to a variety of risks in this type of birth because this procedure can cause a number of complications for the baby; in some instances, even the baby’s death. Some studies report that water births have been known to cause pneumonia, hyponatremic seizures, infections, and drowning (Grunebaum & Chevenauk, 2004, p. 306). Although the baby is indeed immersed in water for 9 months, the delivery is supposed to open up his lungs and prepare for its first gasp of air. Instead, during water births, there is a great risk that their lungs would be filled with water. The water in the tub or pool which may enter the child’s mouth and nostrils may also contain infectious substances and bacteria which would place him at risk for a variety of infections and water-borne diseases. There is also a risk that the mother herself may contaminate the water with her feces and/urine and consequently expose her baby to bacterial infection. Studies were also able to reveal that there were more babies born through water births admitted to the neonatal intensive care unit after their delivery as compared to babies delivered via conventional means (Grunebaum & Chevenauk, 2004, p. 306). Another ethical consideration in this type of birth is when an ill-informed patient would request for the procedure. A patient may approach the midwife and request for a water birth because she thinks it is the most natural and best way to give birth. Some midwives may opt to conduct the procedure without informing the patient of the risks and the fact that the procedure is not the most natural way to give birth. In these instances, there is now an ethical dilemma for the midwife – how can the midwife inform the patient of the risks of the procedure without sounding as if she wants to dissuade the woman from her choice? Ultimately, the midwife is ethically obligated to respect the patient’s choices and preferences. This is the obligation of autonomy of choice that the midwife and all other medical practitioners should respect. However, her responsibility should not stop there, she should properly, accurately and clearly inform the patient not only of the benefits, but also of the risks of the procedure. “Therefore, further discussion would be necessary for the actual autonomous choice to be exercised, as opposed to having the capacity to be autonomous” (Jones & Livingstone, 2000, p. 97). In other words, the patient should have a properly informed consent over the procedures that would be undertaken in her favour. Legal considerations The legal considerations in the matter of water births and the use of water during the first stage of labour mostly revolve around the qualifications of the midwife or medical professional involved in the water birth process. The Midwives Rules and Standards set that a “midwife shall not provide any care which she has not been trained to give” (as quoted by Carter, 2004). If a woman requests for a water birth and the midwife is not trained to carry out such procedure, the latter must decline the woman’s request. The midwife must accept that there are limits to her competence and that she must only undertake such procedures and responsibilities which she can competently administer. These regulations help protect the mother and the child, and ultimately the midwife. The National Health Services also emphasize that women have great control over where and how they give birth. They should be free to choose to give birth in their homes, or in a midwife-led or a consultant-led clinic. Midwives and other health care professionals are obliged to respect the patient’s choices and they are obligated to assist the woman in order to make the best out of her choice. The midwives and medical professionals should not make the patients feel like they are making the wrong choice especially if they opt for the less traditional choices in birthing. A mother who opts for hydrotherapy should be given such opportunity regardless of the opinions of midwives or medical practitioners about the wisdom of such choice (BBC News, 2007). Professional considerations There are various professional considerations in water births and in the use of water in the first stage of labour. First and foremost, monitoring of the foetal heart sound using underwater Doppler should be included as standard practice in water births. In cases where there are concerns about the well-being of the mother and the foetus detected by the Doppler machine, the mother should immediately leave the birthing pool and be checked by an obstetrician. During instances where the mother raised herself out of the water and exposes the foetus to air, the midwife should assist the mother in remaining afloat in order to avoid the re-immersion of the baby. The water birthing process should be ensured as a sterile process at all times. The birthing pool, the water in the pool and all other equipment to be used in the birthing process should all be kept sterile (Alfirevic & Gould, 2006, pp. 3-5). The midwives should also be properly apprised of the physiological basis of maternal and foetal hyperthermia. The midwife should consult with the mother about the water temperature she feels most comfortable in. Such temperatures should be within the safety ranges prescribed by professional practice. The mother’s, the water’s, and the room’s temperatures should be monitored regularly in order to ensure that the extremes of temperature are not experienced by the mother (Garland, 2000). Analgesics should be used and administered to the patient after due consultation with an anaesthetist. The patient should also be consulted prior to labour about the administration of analgesics – if she wants it and what type of analgesic she wants. In case of emergencies, the midwife and other health care professionals in attendance during such birthing process should be aware of their respective actions and responsibilities (Garland, 2000). The midwife should be aware of the fact that hydrotherapy cannot be administered before active labour is established. Due and careful assessment of the mother should be undertaken in order to properly establish her status in the birthing process. Hydrotherapy or water immersion is contraindicated in situations where there is foetal distress and in instances of bleeding. Other complications manifest in both the mother and the baby are also considered contraindications for water births. During these instances, the midwife can recommend the conventional methods of birthing for the mother. Water therapy is also not recommended in instances where birth is already imminent. Immersing the mother in water would no longer serve a purpose, and more importantly, may endanger the life of the baby (Simkin, et.al., 2000, p. 174). The Royal College of Midwives recommend that maternity units should develop guidelines on the use of water during labour and delivery. These guidelines will help establish standards of practice that can be followed by midwives and other health care professionals involved in the water birthing process. Midwives are also required to audit and evaluate their practice. This will help ensure that they are assessing their practice, improving on their skills, and contributing to midwifery knowledge and development. Record keeping in their practice is also an important process that the midwife is required to uphold. This will help ensure that the guidelines of the NHS and all other codes of practice are being consciously adhered to by the midwife regardless of the location or type of birth she is assisting in (Garland, 2000). Finally, the midwife should always keep in mind that there are risks involved in any birthing process. In water births, studies indicate that the baby is put at great risk. It is up to the nurse to adequately inform the mother of the risks which are involved in the process and what she expects the mother to do while the process is underway. By properly informing the mother of the risks and of the things that are expected of her, the mother becomes more conscious of her decision and of her own role. The mother and the midwife are obliged to work together to ensure the success of the procedure. Despite the risks that this procedure carries, many practitioners advocating evidence-based practice declare that this method of birthing is effective and safe (Bowden, et.al., 2003). Water births and the use of water during the first stage of labour is slowly becoming a popular method in child birth. It carries many benefits for the mother, causing less pain and anxiety for her and consequently less anxiety and stress for the baby. There are various ethical and legal considerations in this process and most of these revolve around the safeguards in the procedure that midwives are obliged to follow. Without these safeguards, the procedure is a dangerous and risky procedure to adapt. Works Cited Alfirevic, Z. & Gould, D., April, 2006, Immersion in Water during labour and birth, Royal College of Midwives, viewed 24 July 2009 from http://www.rcm.org.uk/EasySiteWeb/GatewayLink.aspx?alId=25816 Bowden, K., et.al., 4 October 2003, Underwater Birth: Missing the Evidence or Missing the Point?, Neoreviews, viewed 24 July 2009 from http://neoreviews.aappublications.org/cgi/content/full/pediatrics;112/4/97 Carter, J., 12 November 2004, Working with women who make controversial choices about their care, Nursing and Midwifery Council, viewed 24 July 2009 from http://www.nmc-uk.org/aFrameDisplay.aspx?DocumentID=1021 Garland, D., 2000, The use of water in labour and birth, Royal College of Midwives, viewed 24 July 2009 from http://www.rcm.org.uk/EasySiteWeb/GatewayLink.aspx?alId=12774 Grunebaum, A. & Chervenak, F., July 2004, The baby or the bathwater, which should be discarded? Journal of Perinatal Medicine, volume 32, issue 4, pp 306-307 Jones, S. & Livingstone, C., 2000, Ethics in midwifery, London: Mosby Murray, L., et.al., The Babycenter essential guide to pregnancy and birth, USA: Rodale Publishing New NHS guidelines on childbirth, 26 September 2007, BBC News, viewed 24 July 2009 from http://news.bbc.co.uk/2/hi/health/7012295.stm Pairman, S., et.al., Midwifery, New South Wales: Elsevier Australia Simkin, P., et.al., 2000, The labor progress handbook, Massachusetts: Blackwell Water births, May 2007, American Pregnancy Association, viewed 24 July 2009 from http://www.americanpregnancy.org/labornbirth/waterbirth.html Wilson, J. & Symon, A., 2002, Clinical risk management in midwifery, Edinburgh: Elsevier Limited Read More