Water Birth Aspects - Essay Example

? Water Birth Module Module Number Contents Introduction 2 Accessing and Evaluating Current Evidence 4 Review of the Evidence, Research and Guidelines 6 The Professional Role of the Midwife 12 Information Leaflet 14 Conclusion 16 References 17 Introduction Water births have become increasingly common in recent years and have been shown to reduce several complications of childbirth, promote a midwife-like model of care, and to increase the relaxation of the birthing mother (Burns et al, 2012). It is these positive aspects of water births and some of the more interesting complications of this type of birth which have prompted me to become interested in this style of neonatal care and use it as the focus of this project, which will be formed of four main sections. The first section will discuss the style of evidence which was used to fulfill the criteria of later sections, and how this is to be evaluated and used throughout the project. The second section covers the evidence, research and guidelines related to water births and how this is related to best practice. It covers several types of material to give a well-balanced overview of the topic from many angles, each of which is evaluated in depth with respect to water births. The third and final section explores the importance of communication in the relationship between mother and midwife, and how this professional responsibility informs the way that a midwife gives the mother informed consent and fair options about her own care and that of the baby. This information will be looked at in the context of the water birth and how this option fits into the broader practice of midwifery and neonatal care. The final section will comprise of a leaflet designed to present the information collected in the previous sections to assist women in making informed decisions about water births. Accessing and Evaluating Current Evidence Finding good quality academic evidence is important for informing decisions about nursing and for use in informing the public about the safety and applicability of certain medical procedures. These pieces of evidence are normally done by academics or research clinicians that have access to patients and records, and can be used to make deductions about and correlations between certain pieces of information (Steen & Roberts, 2011). These studies are usually conducted with several people and can involve several racial, age and health status groups to ensure that the information provided can be generalized to the population as a whole with respect to certain aspects of healthcare. There are many different types of evidence and research designs, many of which are suitable for discussing water births in the context of midwifery. Firstly, there are statistical studies that are quantitative (number-based), which are used to ascertain the proportion of women who have water births and the types of complication that they generally get (Steen & Roberts, 2011). This allows us to decide whether a practice has too many risks, particularly for the child. There are also psychological studies which are generally qualitative (response-based) which can be used to determine if there are any psychological benefits to the women who choose this method of birthing. Both qualitative and quantitative studies can be used to gauge the level of pain a woman has during various birthing techniques, which can also be useful (Wickham, 2009). Additionally, meta-analyses can be performed (Steen & Roberts, 2011). These look at a group of studies which are relevant to the topic and try to group the findings together to give more weight to the research than a single study would. This helps to improve the generalizability and can give an overview of what types of practice are generally relevant (Wickham, 2009). It is important to identify how research will be done when evaluating practice. In this project, two main databases will be accessed (PUBMED and Medline) to give a wide range of resources on the topic. To find the correct resources, I will be using search strings that are relevant, which are outlined in table 1 below. In many cases, it is possible to do either a subject heading search or a text search. However, it was found that text search yielded more relevant results so is used here. Database: PUBMED Type Text Search Search Terms 1. “waterbirth” OR “water birth” AND “midwife” 2. “waterbirth” OR “water birth” AND “complications” OR “benefits” OR “therapeutic” Limiters Used Since 2002 Number of References Found 1. 699 2. 975 Number of References Used 1. 3 Database: Medline Type Text Search Search Terms 3. “water birth” AND “midwife” AND “meta-analysis” 4. “waterbirth” OR “water birth” AND “hospital” OR “home” Limiters Used Since 2002 Number of References Found 3. 912 4. 777 Number of References Used 2. 1 Table One – Summary of Search Findings The Cochrane review is an important source of information for evidence-based practice, and acts as a systematic review of primary research and therefore will be included for review and information in section 2 of this project. Review of the Evidence, Research and Guidelines One of the most important style of review for evidence-based practice is the Cochrane review, as this is an overarching look at a particular type of medical practice. In one, entitled Immersion in Water in Labour and Birth, Cluett & Burns (2009) review a total of 12 trials relevant to water births, including 3243 women. Given the wide range of studies encapsulated in this review, there are a number of important results discussed. Firstly, immersion in water appeared to decrease the duration of the first stage of labour as well as reduce the amount of intervention needed with respect to epidural/spinal/paracervical analgesia/anaesthesia rates (Cluett & Burns, 2009, p1). There was limited information and thus fewer conclusions with respect to the second stage of labour, although results suggest that immersion during the second stage could lead to a higher level of satisfaction with the birthing process overall (p3). The review also covers the benefits for the neonate, particularly focusing on the improvement in placental oxygen perfusion due to the heightened calm of the mother (p3). The review also addresses some of the concerns many have about water birth, including the risk of infection, and suggest that these are absent or minimal in water birthing techniques, which are generally safe (p4-5). Despite the comprehensiveness of this study, there are a few limitations which make it difficult to draw strong conclusions about certain aspects of immersion at birth. Firstly, there were no reviews included about the use of immersion in water for the third stage of labour, which means that it cannot be recommended based on efficacy in this respect. There are also new reviews included that discuss the type of immersion pool or bath that is the most effective in giving the benefits described above, which means that the advice regarding water birth must be generalized in this area. Thoni et al (2010) completed a large review retrospectively of 2625 water births. The variables in these cases were the length of labour, the amount of tears, analgesic requirements, shoulder dystocia and delivery after a previous ceasarian section (p203), which increases the generalizability of the review to various different women. Unlike the Cluett & Burns (2009) paper, this review did find evidence that the microbial load of the water bath post-partum and the incidence of neonatal infections was higher in water birth than in conventional births. It should be noted that the overall conclusion is that this increase in infection was below a significant level and therefore water births can be said to be just as safe as normal delivery, and that the risks are outweighed by the benefits. Many of the findings were similar to that of Cluett & Burns (2009). The length of labour was found to be reduced in the majority of cases, as was the incidence of episiotomy and tearing (p209). Again, the overall view of the women involved in this study was that water birth was a psychologically pleasant experience when compared with traditional births, suggesting that water birth may be beneficial in this way. However, as with most studies, there are issues with using the information found in this study. Firstly, there is no review of the type of water bath or pool used, so this cannot be taken into account when assessing the nature of water birth. Secondly, the study was done retrospectively on water births conducted between 1997 and 2009, meaning that some of the information is likely to be outdated. Overall, however, this study supports the beneficial nature of water birthing. Another general observational study was conducted by Burns et al (2012) on 7915 women. The large size of this study means that the results are less liable to bias and therefore should give a strong basis upon which to form evidence-based practice ideas regarding water birth. This study has a strong focus on the frequency of spontaneous birth in women that used birthing pools, and suggested that birthing pools give an increased rate particularly in nulliparas, although this can vary widely between locations within the UK (p199). The study, like those described previously, came to the conclusion that water births are generally beneficial to mother and child and do not pose any significant risk. The major positive point of this paper is that it gives strong recommendations regarding traction on the cord, suggesting that it is important to prevent this when guiding the baby to the surface to minimize complications (p199). Overall, this research is incredibly useful and has high validity and generalizability. The main criticism of the research is that it does not go into the differences between different maternity wards and clinics to find out why there are underlying differences in outcomes and how this could be related to type of pool or bath, which would be useful when advising mothers-to-be in evidence-based practice. Carpenter & Weston (2012) conducted a study regarding one of the topics that comes up time and time again in discussions of water birth – respiratory distress. Carpenter & Weston (2012) suggested that many people are worried about the respiratory consequences for the neonate in water birth, and studied the effects in 14 babies born in water and 24 air birth babies. The study was conducted on low-risk babies with respiratory distress and the information gathered using x-ray and clinical features to allow for discussion of the physiological consequences of water birth. The results showed that ‘water birth babies showed greater acidosis, greater requirement for ventilation, greater requirement for nitric oxide treatment and greater time to establish feeding’ (p419), suggesting that there may be a higher level of complication in some cases. However, the low number of neonates included in this study (38 in total) means that it lacks generalizability and is prone to bias. Additionally, the presence of complications is higher in babies who show signs of respiratory distress, and therefore does not necessarily mean that these complications will occur in all babies, particularly in the healthy ones. However, it is worth nothing that water births are not necessarily appropriate for all women, and this study highlights the fact that there are possible dangers associated with this type of birth which should be noted as part of evidence-based practice and when giving information to women considering this method. Davies (2010) explores the necessity for a good quality study into the process of water births to assess the benefits and possible harms from a scientific perspective. The possible problems are highlighted to a great extent in this review, focusing on infection and respiratory problems, and this is useful in understanding that water birthing is a fairly new phenomenon and should be viewed with care. Davies (2010) also suggests that there be no babies born into water unless they are part of such a review, meaning that it would not be recommended to women without certain precautions. It is worth noting that this paper is based heavily on opinions (rather than the strong scientific basis of the previous papers), and there are several studies which have been conducted on water birthed neonates which demonstrate benefits and little possible harm, which should not be ignored. Evidently these five pieces of research give a lot of information, much of which can be used in evidence-based practice and incorporated into current recommendations regarding water birth. Current recommendations suggest that water birthing is an available option to women who are likely to have uncomplicated births and are healthy (Wickham, 2009). The research above supports this. The Carpenter & Weston (2012) study suggests that water births may be more dangerous in babies with respiratory distress, and therefore water births should not be indicted for women who may be likely to have this type of complication. There are currently no recommendations with respect to the type of pool or bath that is recommended for water births, as they can be purchased or hired for home use or used within a hospital setting (Wickham, 2009). This information is largely missing from the research and therefore no strong recommendations can be made about which setting and which type of pool is likely to be the most beneficial. Overall, the evidence suggests that water births are a safe and highly therapeutic option with a huge number of benefits including lowered distress and a possibly lower labour time, and carry minimal risks. The Professional Role of the Midwife Having explored the evidence relating to midwifery and water births, it is important to explore how the midwife plays a professional role in this process and how the information above can be communicated clearly to the prospective mother. Communication is extremely important for midwives as there are a lot of different choices with respect to birthing options and many women can feel overwhelmed and unable to make a strong decision without support (Wickham, 2009). Communication with the midwife has been shown to be one of the most important and influential sources of information for a pregnant woman, particularly about her choice of birth (Wickham, 2009). As water births are becoming a more popular option, it is important for the midwife to understand the information given above and to put it into a professional context to give good advice. Although midwives are an important source of information for women, there are many different forms of communication which may be more appropriate for certain people and situations. For example, there may be those who prefer to be given information in the form of a leaflet or print-out to take home, discuss and choose in their own personal time. This makes it important to give factual information in this format, and to have it available for this form of communication. Midwives could also encourage discussions between the mother and the father of the baby (where appropriate) to facilitate an opinion being formed for both parties, which may be beneficial and improve the birthing process. Informed choice is centered around this concept of communication. A midwife communicating this information with respect to birthing options is the best way for a woman to know all the options and their risks and benefits and to make a choice from these options. For example, water birthing is becoming increasingly popular (Wickham, 2009), but many women still do not consider it a viable option or may have concerns about infections or respiratory distress in their children. A midwife presenting information about water births can help dispel the myths about this type of birth and help a woman make the choice between this and a traditional air birth in an informed manner. Informed consent is linked to this concept, as a women cannot give her consent about the type of birth she and her baby require without having proper knowledge about the options available. As previously mentioned, a midwife is amongst the most important people in facilitating informed consent and decision-making for mother and baby. This is because a midwife is in a trusted position of care (Wickham, 2009) and is expected to know about all the complications and benefits, both academically and from experience. For example, a midwife can understand that a water birth is likely to reduce the time taken for the first stage of labour, and can incorporate this information with what is currently considered best practice within the NHS and with personal experience about the timing of water births. A similar approach can be taken with respect to pain, as a midwife will know the levels of analgesics and anaesthetics involved in both a typical birth and a water birth. It is this kind of information which a midwife can communicate to a mother and help her to make a proper decision about her personal care. A midwife needs to incorporate all the elements of communication described above to facilitate easy decision-making and most importantly to promote the healthy and happy birth of the child. Information Leaflet Water Birth – Is It For You? What is a water birth? A water birth involves spending part or all of the labour process immersed in water. What are the potential benefits of water birth? Water birthing is a relatively new concept in midwifery, and therefore the benefits are not as widely known as in other areas of birthing care. However, there is evidence that it can shorten parts of the labour process, decrease pain in contractions and the need for painkilling intervention, and can help you to relax and have a more positive birthing experience. Are there any risks? There may be a slightly higher risk of infection, although this is generally low. Hospitals have to maintain a certain standard of cleanliness in the birthing pools which eliminates a number of the risks in this area. The other possible risks are generally only seen with women in high-risk groups, so water births aren’t generally recommended in certain circumstances, such as when carrying twins or triplets, if you’ve had a previous ceasarian section, or if your baby is breech. Your midwife will be able to advise you about whether a water birth is right for you. What do I need to think about? Water births aren’t available everywhere. This means that if you want a water birth, you may have to have the baby at home with a midwife supervising, in a hired or bought pool for the purpose. You should also think about the different options available, and remember that you will not be able to have any electronic assistance such as the TENS machine. Finally, you could have a look at the different facilities and talk to your midwife, doctor and partner to see if a water birth is for you. Conclusion Evidently, there are a lot of elements to consider when recommending a water birth to a woman. The literature suggests that there are many positive elements, such as the reduced need for painkilling regimens, and an increase in the time taken for the first stage of childbirth. Additionally, women who have had a water birth have reported a more pleasant birthing experience, which is something which needs to be highlighted when giving advice. There are, of course, things to be wary of with such a new method of birthing, including the possibility for an increased risk of infection and breathing problems in the child, but these appear to be largely unsubstantiated by the literature. Communicating these things to the woman is important for the midwife as they hold a position of trust and are often the liaison between clinical information and informed decisions and consent. Recognising this helps to improve the standard of care that can be given to a women and informing them of the most appropriate way of giving birth, for them. Additionally, it may be helpful to give them understandable take-home information in the form of a leaflet or guidance notes to supplement the support given by the midwife. Taking all this into account, it seems that giving the individual the choice on water birth as a healthy and safe option for mother and baby is completely appropriate and is worth opening up to discussion between mother and mifwife. References Burns, E.E., Boulton, M.G., Cluett, E., Cornelius, V.R., Smith, L.A., 2012. Characteristics, Interventions, and Outcomes of Women Who Used a Birthing Pool: A Prospective Observational Study. Birth 39, 192–202. Carpenter, L., Weston, P., 2012. Neonatal respiratory consequences from water birth. Journal of Paediatrics and Child Health 48, 419–423. Cluett, E.R., Burns, E., 2009. Immersion in water in labour and birth, in: The Cochrane Collaboration, Cluett, E.R. (Eds.), Cochrane Database of Systematic Reviews. John Wiley & Sons, Ltd, Chichester, UK. Davies, M.W., 2012. Water births and the research required to assess the benefits versus the harms. Journal of Paediatrics and Child Health 48, 726–729. Steen, M., Roberts, T., 2011. The Handbook of Midwifery Research. John Wiley & Sons. Thoni, A., Mussner, K., Ploner, F., 2010. [Water birthing: retrospective review of 2625 water births. Contamination of birth pool water and risk of microbial cross-infection]. Minerva Ginecol 62, 203–211. Wickham, S., 2009. Midwifery: Best Practice. Elsevier Health Sciences. Read More