The Coombe Women and Infants University Hospital in Dublin is one of the largest maternity hospitals in Ireland. Our mission statement is ‘excellence in the care of women and babies’ and that is what we strive for.  The hospital promotes normality in childbirth and is committed to providing high quality, evidence-based care for all women. 

In 2013, the The Coombe Women and  Infants University Hospital made a birthing pool available to offer an alternative form of non-pharmacological analgesia to women in labour. Initially, the pool was used for labour only, and women were asked to exit the pool for birth. But in recent times, the option of water birth has been made available to women and, to date, 10 babies have been born under water.

Pools are also available in the midwife-led units in Cavan, Drogheda and in Cork University Maternity Hospital. A letter of guidance was circulated by the Health Service Executive in 2009 on ‘Use of Water for Labour and Birth’. This recommends that all units providing birthing pools should put in place protocols and best practice guidelines regarding staff training, infection control, inclusion/exclusion criteria, and clinical audit and risk management. They also recommended that women wishing to use water for labour and/or birth should be made aware of the potential risk of water intoxication, and their informed consent to use hydrotherapy be obtained and documented.

The benefits of water include greater relaxation for women, shorter labours, less painful contractions¹ and reduced need for analgesics, including epidural/spinal analgesia.² One study also showed fewer episiotomies and less perineal trauma.³ Hydrotherapy is effective due to heat and ‘hydro kinesis’. Heat relieves spasm in muscles and therefore reduces pain, and ‘hydro kinesis’ reduces gravitational force and thus reduces pelvic discomfort and strain.³ In the buoyant water, women can move more easily, which helps alleviate pain and enhance labour progress.⁴ As immersion in water early in labour seems to be associated with prolonged labour,⁵ it is recommended that women be encouraged to mobilise on land until labour is established.

Other outcomes (Caesarean section, instrumental birth, maternal infection, Apgar scores, neonatal admissions, neonatal infection) showed no significant difference in a comprehensive Cochrane Review of 11 randomised trials.² Another large observational study of 8,924 women at low risk of childbirth complications who used a pool during labour found that 7,915 (88.9%) had a spontaneous birth and 5,192 (58.3%) birthed in water.¹ The umbilical cord snapped in 18 babies birthed in water and in two babies birthed on land, so the authors emphasised the importance of not exerting undue traction on the cord as the baby is brought to the surface.

For healthy women with uncomplicated pregnancies, the Royal College of Midwives and Royal College of Obstetricians and Gynaecologists support labouring in water.⁶ As the benefits of birthing in water are less clear, they recommend that eligible women should have the option of hydrotherapy in labour and should be able to choose to birth in water if they wish.

Before The Coombe Women and Infants University Hospital put the birthing pool into use, an evidence-based guideline for clinicians was drawn up and agreed by the multidisciplinary team. The procedure for using the pool was outlined, including eligibility criteria. Caring for women wishing to use the pool was a new concept for many midwives. For this reason, a series of workshops was held with the assistance of Dr Ethel Burns, senior midwifery lecturer and water birth ‘guru’, from Brookes University and John Radcliffe Hospital, in Oxford in the UK.  A number of our midwives also spent time in the Ulster Hospital in Belfast, where there is a considerable number of water births annually, in order to witness and learn from their practice. 

Our hospital guideline was amended in July of this year to reflect the enabling of women to choose water birth if they so wished. To date, more than 100 women have used the pool and 10 out of the last 20 women who have used the pool have chosen to give birth underwater. To date, when one looks at the outcomes of all women who have used the pool for any amount of time, there appears to be a trend towards normal birth, with a  spontaneous vaginal delivery (SVD) rate of 80%, and a reduction in use of pharmacological analgesia (epidural rate of 18%, compared with an average of 44% epidural rate for all women (as set out in 2012 Annual Clinical Report). 

Verbal feedback from some women included:

• “Excellent, relaxing, a distraction”
•  “Even hearing the pool filling as we walked in the room was lovely”
• “A very positive experience”  
• “Bliss!”
• “Was really helpful to change positions” 
• “Loved the shower on my back”
• •“Felt the contractions were stronger in pool” 
• Comments from midwives included: 
• •“Lovely experience, the woman was always in control” 
• “Being the first time, I was nervous, but enjoyed it”
• “The most amazing experience of my midwifery career to date”.

The introduction of the birthing pool into the care package provided for women attending our hospital has met with approval, goodwill and enthusiasm from women and their families, midwives, obstetricians, neonatologists as well as staff from the professions aligned to medicine and our support staff. 

This has been down to the pride, passion and professionalism by all the staff involved in this important initiative. It has involved commitment, good communication, interdisciplinary respect, rigorous attention to detail, evidence-based care, guideline development, audit, informed choice. This arose from a desire to advocate for women and babies and to innovate and create safe and sustainable choices in care. More Irish maternity units should consider this excellent means of pain relief.

Finally, we would like to acknowledge the support we received from the senior management team of The Coombe Women and Infants University Hospital; the Capital Project Team; the board of guardians and directors, the Friends of the Coombe, the Centre for Midwifery Education and the Ulster Hospital, Dundonald, Belfast.   

References

1. Burn  E, Boulton MG, Cluett E, Cornelius VR and Smith LA. Characteristics, intervention and outcomes of women who used a birthing pool: a prospective observational study. Birth 2012 ; 39.3: 192-202
2. Cluett ER, Burns E. Immersion in water in labour and birth. Cochrane Database of Systematic Reviews 2009; Issue 2, Art. No.: CD000111. DOI: 10.1002/14651858.CD000111.pub3
3. Garland D. Revisiting Water Birth – An Attitude to Care. 2010 ; Third Edition. Edinburgh: Books for Midwives, Elsevier Limited
4. Garland D, Jones K. Water Birth: supporting practice with clinical audit. MIDIRS Midwifery Digest 2000; 10(3), 333-336
5. Eriksson et al. Early or late bath during the first stage of labour: a randomised study of 200 women. Midwifery  1997 ; 13: 146-148
6. Royal College of Obstetricians and Gynaecologists/Royal College of Midwives Joint Statement No. 1. Immersion in Water During Labour and Birth. London: RCOG/RCM, 2009
7. Royal College of Obstetricians and Gynaecologists (2001) Birth in Water. RCOG Statement. London: RCOG
8. National Collaborating Centre for Women’s and Children’s Health. Intrapartum Care: Care of Healthy Women and their Babies During Childbirth. London: Royal College of Obstetricians and Gynaecologists, 2007