CLINICAL PRACTICE GUIDELINE
Water immersion for pain management during the
first stage of labour
SCOPE (Area): Maternity
SCOPE (Staff): Midwifery & Medical
BACKGROUND/RATIONALE
Immersion in water during the first stage of labour has been associated with a lower incidence of
epidural analgesia and reported maternal pain without adversely affecting labour duration, operative
delivery rates and neonatal wellbeing.
DESIRED OUTCOME/OBJECTIVE
To enable caregivers to provide care that is as safe as possible for healthy pregnant women who
choose to use immersion in water as a pain management strategy during the first stage of labour
NOTE
Water immersion in the second stage of labour is not recommended at Ballarat Health Services
INDICATIONS
Antepartum
The following women may be offered the option of being immersed in water during the first stage
of labour:
Healthy women with no medical or obstetric risk factors
Singleton pregnancy
Cephalic presentation
At least 37 completed weeks pregnant
Not a carrier of / infected with HIV, Hepatitis B or Hepatitis C virus
Body mass index(BMI) <35 at term
Established labour with cervical dilatation preferably >4cm (see ‘Issues to consider’)
Consideration of the following:
Positive Group B Streptococcus vaginal swabs during pregnancy are not a primary
contraindication for water immersion
Women with ruptured membranes for more than 18 - 24 hours may be offered the option of
being immersed in water during labour and birth, after commencing the recommended
course of intravenous antibiotics
CPG/W000: Water immersion for pain management during the first stage of labour (2011)
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Intrapartum
In the intrapartum period the following additional criteria need be taken into consideration:
There is no contra-indication to the use of intermittent auscultation of the fetal heart
All maternal and fetal observations remain within normal range
The woman understands that she is required to leave the water if an intrapartum risk factor
develops or is detected
There is clear amniotic fluid in the presence of a reassuring fetal heart rate
The woman understands that she must leave the water for the second stage of labour
CONTRAINDICATIONS
Women with pregnancy complications should not enter the bath in labour. This includes but is not
be limited to:
The need for continuous electronic fetal surveillance during labour
Intrapartum haemorrhage
Epidural analgesia
Fetal heart rate abnormalities
Active maternal infection (e.g. HIV, Hepatitis B,C, herpes or skin lesions)
Malpresentation
Body mass index >35 at term
ISSUES TO CONSIDER
Staff must be aware of the correct procedure to assist the women to leave the water in an
emergency situation. Adequate staffing levels in the unit must be maintained to assist with this
procedure if a woman is in the bath
Discussion of the benefits, inclusion and exclusion criteria for the use of immersion in water in
labour is recommended during the antenatal period to ensure the woman and her support
persons are fully informed prior to presenting in labour
The midwife or support person must remain with the woman at all times to maintain safety
whilst she is immersed in water
The use of narcotic analgesia in the previous 4 hours may limit a woman’s ability to safety enter
and exit the bath. Whilst it is not recommended that a woman enter the bath within 4 hours of
narcotic analgesia use each case must be assessed on an individual basis as each woman’s
tolerance to the drug can differ. Consideration must be given to the woman’s conscious state
and her ability to leave the bath in an emergency and the assessment must be documented
The timing of entry to the bath remains somewhat inconclusive. There is some evidence to
suggest that progress of labour may be delayed if the woman enters the bath at a cervical
dilation of less than 4cm. This has been described in the literature in terms of an increased
incidence of epidural rates and an increased need for augmentation of labour. There is also
some evidence to suggest water immersion can also augment labour. These issues may be
considered when discussing pain relief options however the woman should not be restricted
from entering the bath if it is her desire to do so.
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Criteria for exiting the birth pool
Signs of potential fetal compromise
Maternal distress
Maternal request for analgesia other than nitrous oxide and oxygen gas (see ‘Issues to
consider’)
Maternal choice
If contractions reduce or become ineffective (the woman may be able to re-enter the bath
when contractions improve)
Prolonged /slow progress of labour despite adequate contractions
Risks / complications
Infection
Maternal hyperthermia
Delay in the woman removing herself from the bath when requested to do so might result in
o unplanned birth through water
o a delay in instigating emergency measures where indicated.
Management of an unplanned water birth
The woman must be asked to leave the water for the second stage of labour however in the
circumstance that she is unable or refuses to leave the water, when birth is imminent:
The baby must be born completely underwater with no air contact until he/she is brought
gently to the surface immediately after the body is born. A ‘hands off’ technique must be
used to minimize stimulation of the baby under water. It is not necessary to feel for the
presence of the nuchal cord however it may be loosened and disentangled once the baby is
born
Once the head is delivered observation for shoulder dystocia must be performed. If signs of
shoulder dystocia are present the woman must leave the water and emergency procedures
instigated
If the woman is able to stand up to birth her baby into air it is important that once the
presenting part is visible she must remain out of the water to avoid the risk of premature
gasping under water. At this stage the water should be drained from the bath
If the cord is around the baby’s neck tightly and needs to be cut then the woman must be
assisted to stand out of the water and remain out of the water for the remainder of the birth
Avoid undue traction on the cord as the baby is brought to the surface of the water to
minimise the risk of the cord snapping
Under no circumstance should the cord be clamped and cut under water and this process
stimulates the baby to breath
Under no circumstance should the baby’s head be resubmerged under the water
Dry the exposed head and skin to reduce heat loss and maintain skin to skin contact with the
mother
Apgar scores must be assessed at time of birth and not time of removal from water
If resuscitation of the baby is required, the cord must be clamped and cut and the baby taken
immediately to the resuscitation cot
Intramuscular injection should not be given under water and it is preferable to use the
deltoid if while the woman is still in the bath
The woman must be asked to leave the bath for management of third stage
Ensure comprehensive documentation
CPG/W000: Water immersion for pain management during the first stage of labour (2011)
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EQUIPMENT
Deep bath, accessible both sides with a bath plug with chain attached
Medical gases for resuscitation must be available for the bathroom (portable oxygen and suction
located at labour ward desk)
Water thermometer
Maternal thermometer
Long gloves
Waterproof fetal doppler
Waterproof gown
Sieve to remove maternal faecal contaminants
Padded floor mat, kneeling pads, cushions or a low stool to ensure occupational health and
safety for the midwife and support persons
Oral fluids for hydration
PROCEDURE
PROCESS STANDARDS:
Assessment
1. Women must be fully assessed for
maternal and fetal wellbeing prior to entry
in the bath
2.
Labour progress must be assessed prior to
entry into the bath
Bath preparation
3. Run the taps on full for several minutes
before filling the bath
4.
Fill the bath with pure tap water (no
additives)
5.
The water level should be to the maternal
breast level when sitting and not above the
auxilla
6.
The woman should be comfortable with
the water temperature. This would be
expected to be between 35-37°C
7.
Keep the water as clean as possible using a
sieve
KEYPOINTS:
Women with antenatal risk factors or
contraindications to the use of the bath in
labour must be identified during the
admission process and made aware of the
reasons
Ensure the woman is not close to the second
stage of labour
Reduces the
pseudomonas
risk
of
transmission
of
There is some evidence that additives,
especially bath oils, in the water may affect
the fetus
Promote comfort and prevent maternal
pyrexia and tachycardia
Minimise faecal contamination and reduce
the risk of infection. If the water becomes
heavily contaminated the woman must be
asked to leave the water and the bath must
be cleaned and refilled
CPG/W000: Water immersion for pain management during the first stage of labour (2011)
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Observations
8. Assess maternal and fetal observations
prior to the woman entering the water
9.
Provides a baseline for continual assessment
and excludes any risk factors
Maternal temperature must be assessed
and recorded hourly
Temperature is expected to remain in range.
A rise in maternal temperature may indicate
that the water temperature is too hot and may
result in fetal tachycardia. If the woman’s
temperature is raised she must leave the
water until it has returned to normal. If the
maternal temperature remains unstable it
may indicate the presence of dehydration or
infection
10. If the maternal temperature is greater than
37.6°C on 2 occasions the woman should
leave the water. A full assessment must be
then completed including maternal and
fetal wellbeing including fetal surveillance
FHR monitoring is performed using a water
proof Doppler. The midwife must wear long
gloves when obtaining FHR and/or the
woman may lift herself out of the water
briefly
11. Fetal heart rate (FHR) monitoring and
maternal observations must be performed
according to normal guidelines
Staff are encourage to use a mat or low stool
when taking a woman’s vital signs to reduce
bending
12. Document times of entering and leaving
the water including the reason for leaving
13. Check and document the water
temperature hourly on the Partogram
General Care
14. Encourage the woman to drink frequently
To prevent dehydration
15. Encourage the woman to leave the water
to urinate 2 hourly
16. The woman must leave the water for a
vaginal examinations
The woman must leave the bath prior to the
second stage of labour or when the signs
become obvious.
Analgesia
17. Nitrous oxide and oxygen gas may be used
in the bath if required (portable unit
available)
Emergency Management
Should not affect the woman’s capacity to
leave the water if requested
Consider waiting 4 hours after using narcotic
analgesia before entering the bath (see
‘Issues to consider’)
18. If the woman becomes unresponsive in the
bath a Code Blue must be called and
appropriate
emergency
management
procedures followed
CPG/W000: Water immersion for pain management during the first stage of labour (2011)
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19. The woman must be removed from the
bath in order to initiate resuscitation.
Appropriate manual handling procedures
must be followed and assistance may be
sought from the woman’s partner.
There must be adequate staffing levels on
the ward at all times whilst a woman is in the
bath to expedite removal from the bath in an
emergency situation
REFERENCES
Australian College of Midwives (2005) The use of water during labour and birth. Accessed on 14/4/11 from
http://www.midwives.org.au/lib/pdf/documents/The%20Use%20of%20Water%20During%20Labour%20and%20Birth.
pdf
Government of South Australia Department of Health (2007) Policy – First stage of labour in water Accessed on
14/4/11 from http://www.publications.health.sa.gov.au/cgi/viewcontent.cgi?article=1008&context=pol&seiredir=1#search="water+in+labour+guidelines"
National Collaborating Centre for Women’s and Children’s Health (2007) Clinical Guideline Intrapartum Care – Care
of healthy women and their babies during childbirth. Accessed on 3/6/11 from http://www.nice.org.uk
Southern Health (2009) Clinical Practice Guideline – Water birth – immersion in water during labour and birth
guideline. Accessed on 14/4/11 from
http://www.southernhealth.org.au/icms_docs/1911_Water_birth__immersion_in_water_during_labour_and_birth_guideline.pdf
Royal College of Obstetricians and Gynaecologists and Royal College of Midwives (2006) Joint Statement No.1
Immersion in water during labour and birth Accessed on 14/4/11 from http://www.rcog.org.uk/files/rcogcorp/uploaded-files/JointStatmentBirthInWater2006.pdf
The Women’s (2006) Clinical Practice Gudielines -Water immersion – First stage of labour – care of women Accessed
on 14/4/11 from
http://www.thewomens.org.au/WaterImmersionFirstStageofLabourCareofWomen?searchTerms[]=water&searchTerms[
]=immersion%3A&searchTerms[]=first&searchTerms[]=stage&searchTerms[]=of&searchTerms[]=labour%3A&search
Terms[]=care&searchTerms[]=of&searchTerms[]=women
Women’s & Newborns’ Health Network (2009) WA Labour and birth in water – Clinical Guidelines for women
requesting immersion in water for pain management during labour and/or birth. Accessed on 14/4/11 from
www.health.wa.gov.au/circularsnew/attachments/426.pdf
Reg. Authority:
Date Effective:
Date Revised:
Review Responsibility:
Date for Review:
Original Author: Midwifery Project Officer, Midwife OH&S Portfolio (2011)
Updated by: -
CPG/W000: Water immersion for pain management during the first stage of labour (2011)
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