Water birth - Dissertation Example

Running head: VBAC & water birth VBAC & water birth Ref: VBAC & water birth Introduction The birth of a baby is a highly emotive time for a woman, and can be influenced greatly by a previous birth. This is frequently seen in the instance of women who wish to have a vaginal birth when they have had a caesarean section in the past. A VBAC has been seen as a high risk birth, and women have frequently been managed by obstetricians, who insist on women having continuous ctc (cardiotochography) monitoring and studies have shown women have felt that they did not have the birth they would have liked. In contrast, many women have waterbirths and praise the experience they have, and as VBAC becomes more acceptable for midwives to manage, with homebirth vbac becoming more acceptable. Waterbirth VBAC has only recently been seen in the midwifery literature, with a 3-year trial in Maidstone (Garland 2006) however, anecdotally, it has been happening for many years. The purpose of the literature review is to gain an in depth, comprehensive knowledge of the subject area, examine what research or studies have been undertaken, avoid repetition of previous studies and enrich study being planned and anticipated (Couchman and Dawson, 1995). To achieve this, the author conducted a comprehensive literature search using several medical literature databases, as well as internet search engines. A summary of this literature searching strategy can be found in appendix 2. In addition personal communication via email to vbac support groups in both the UK and America, elicited a number of articles, which are recommended to women who wish to consider VBAC.The pertinent themes, which recur in the literature, will be critically analysed and explored. These themes are as follows: Maternal choice, maternal morbidity and mortality with VBAC-uterine rupture, infection, maternal morbidity and mortality with water birth water embolus infection, foetal morbidity and mortality with VBAC, foetal morbidity and mortality with waterbirth. Uterine rupture is one of the complications that can occur during pregnancy. In the context of vaginal birth after cesarean, this is treated as a major childbirth complication or VBAC (RCM, 1998). UKCC (1992), notes that uterine rapture refers to any of the following, a weak spot in the uterus wall or the unfortunate of tearing the uterus leading to tissue injury to the fetus. This situation is worse than the former and the blood leaks to the mother’s abdomen. In a study carried out by, on the effectiveness of cesarean section, Brown, (1999), notes that, cesarean on the upper muscular portion increased the risk of uterine rupture n mothers. Brown, (1999) adds that previous classical cesareans, involving incision near the top of the uterus, history of fibroid tumors especially cases whereby incisions go beyond the full diameter of the uterus wall, and all uterus surgery that go past the muscular part of the uterine wall, or more than three /multiple previous low transverse cesareans all have the potential to significantly increase a pregnant woman’s risk. According to Tookey, and Gilbert, (1999), the precedence of having had over five full-term normal pregnancies, abnormal positioning of the fetus, an overdistended uterine wall as well as use of labor-inducing medications such as prostaglandins and pitocin do increase the risk. In line with the findings from a study by (Tookey, & Gilbert, 1999), it was observed that, first-trimester abortion, the removal of superficial fibroids, D&C, or non-uterine pelvic surgery, did not increase uterine rupture risk. Tookey, & Gilbert, (1999) also identifies two types of ruptures, the mild type which does not manifest symptoms and therefore does not pose any danger for the baby or mother. Tookey, & Gilbert, (1999) adds that this type of rupture is only discovered coincidentally during other surgery operations. It is the severe uterine rupture which is dangerous since it may be so large that it affects several uterine blood vessels, (Steer, & Deans, 1995). In the case of severe uterine rupture, the mother loses blood and may cause permanent damage to the uterus leading to its removal also known as (hysterectomy). Steer, and Deans, (1995) adds that death of the baby often result due to lack of oxygen. In a study involving mothers with a history of low transverse cesarean it was observed that uterine rupture could occur before or in the process of labor. The study established that the risk of rupture was 1 in every 625 women going for repeat cesarean without labor, but significantly, only1 out of every 192 women opted for VBAC, the study further added that, the risk was 1 out of every 129 women who had labor induction without prostaglandins, and 1 out of every 41in cases whereby prostaglandin was used for induction. On resultant deaths, it was observed that uterus rupture was responsible for the death of 1 in every 18 babies who died, but only 1 out of every 23 cases of women experiencing uterine rupture warranted hysterectomy. In conclusion the study observed that, the risks of losing the baby was far much higher in women choosing VBAC with no use of prostaglandins, (1 baby out of every 3,500 labors) while for elective repeat cesareans only 1 out of every 11,000 was lost. How to detect uterine rupture. According to New England Journal of Medicine (2001), severe and localized pain, abnormal fetal heart rate, and vaginal bleeding are all pointers to danger of uterine rupture. New England Journal of Medicine, (2001) further notes that caregivers as well as mothers should watch out for the above and arrange for an emergency cesarean to salvage the fetus. Prevention of uterine rupture. Uterine ruptures taking place before labor is regarded as unpreventable. But according to, Brown (1999), mothers who are in higher risk is better off not attempting labor at all. The other suggestion is that women at an increased risk should insist on continuous fetal monitoring in the entire labor duration. According to New England Journal of Medicine (July 5, 2001) issue if labor is induced using prostaglandin medications after a prior cesarean, the risk of uterine rupture is put at a very high chances. Vaginal Birth after Cesarean (VBAC). (Burns, and Kitzinger, (2000) reported that, mothers with a prior low transverse cesarean have only three options of birth modes: Repeat cesarean without labor. VBAC. Labor before cesarean. Of all the three above Burns, and Kitzinger, (2000) recommends vaginal birth as the safest in that vaginal birth facilitates proper functioning of the baby’s lungs as well as quicker recovery of the mother. Brown (1999) also terms vaginal birth as quick and more comfortable compared to cesarean. According to Steer, and Deans, (1995) the concern although not really a threat is in cases uterine rupture but Steer, and Deans, (1995) quickly add that this is a rare occurrence, which cannot jeopardize the survival of mother or the baby. According to (Tookey, & Gilbert, 1999) a repeat cesarean is also safe but like it is in all surgeries, it has its risk. As for laboring before finally settling for cesarean, Steer, and Deans (1995) notes that high chances of infection as well as exhaustion make it riskier than the above mentioned methods. Advantages of repeat cesarean. (House of Commons Health Committee, 1992) report mentions the advantages of repeat cesarean operation as convenience in terms of childcare, avoidance of labor-then-cesarean process and lesser risk of uterine rupture. However, Steer, and Deans, (1995) adds that a higher chance of fluid from lungs (TTN), inexact prediction, and surgical complications, much difficult in recovery are all constraints associated with repeat cesarean. Vaginal birth. As noted by RCM, (1998), key advantages of vaginal birth include: Faster recovery than in cesarean. More psychological satisfaction. Fewer for mother and baby as well as satisfaction and self-reassurance arising from the fact that a mother attempted vaginal birth. On the other hand (RCM, 1998) adds that, there are nevertheless constrainants which come with vaginal birth, they particularly cite, complication of uterine rupture, increased risk for infection especially in cases of labor then cesarean, and emergency cesarean as possible problems associated with vaginal birth. In regard to which birth mode is better for mothers (UKCC, 1992) noted that it all boils down to mother’s preference and choice given the amount of information they have, advice from caregivers, social cultural issues as well as past experience of the mothers. All in all, the choice cannot be generalized and different situations may favor different modes of birth. Role of physicians in maternal choice of birth mode. The key role of a physician is that of advisory (UKCC, 1992), in matters of maternal choice, it is the prerogative of physicians to create room and prepare for emergency situations no mater the birth mode chosen by the mother since as noted by Steer and Deans, (1995), all modes consist of potential danger to both the mothers and child life. Steer, and Deans, (1995) defines uterine rupture as the unexpected tearing of the uterus into the abdomen. Tookey, and Gilbert, (1999) notes that uterine rupture leads to a sudden fetal bradycardia, hence necessitating surgery to save the lives of both the child and the mother. Maternal morbidity and mortality. According to UKCC (1992) VBAC is a safe and reliable means of avoiding morbidity associated with repeat cesarean. Burns and Kitzinger (2000) observed that VBAC main theme is to minimize cases of surgical deliveries, therefore reducing cesarean section. In a study by RCM (1998) it was reported that that by 1995, cases of cesarean sections had dropped by 2o percent in the U.S as a result of promoting VBAC.This trend though seems to have changed due to incidences of poor maternal and fetal outcomes when VBAC fails. According to, Garland, and Jones, (2000), the other risk of waterbirth is drowning but he adds that in as many births underwater, no cases of drowning have ever been reported. Underwater birth is now deemed an acceptable type of delivery. However, Nikodem, (2000) warns that safety is only expected in cases whereby, the procedure of waterbirth is done properly. In a study on the safety of waterbirths, Beech, (2000), concluded that, waterbirths delivered by professionals were as safe as the normal vaginal deliveries and did not pose any increased danger to the baby nor the mother. In a study to determine the length of time taken by waterbirth, Schorn, McAllister, Blanco (1993) found out that there was a significant time reduction in labor, especially the first part, the report further added that episiotomies and perineum lacerations were found to be significantly in waterbirths. This was also supported by, Beech, (2000), who observed that childbirth is not only safe but it also is a good intrapartum intervention. According to, Jessiman, & Byers, (2000), waterbirth does not slow down labor as long as a mother is in established labor, on the contrary water leads to the relaxation of the mother and therefore speeding up of the delivery process. However, McCandlish, & Renfrew, (1993) advices that mothers should get out of the pool once they notice sign of slowed up labor as a result of being in the water. Whether waterbirth can increase chances of infection is still debatable but as, Nikodem, (2000) notes, it depends much on whether the mother gives birth in the water or outside. In a study by McCandlish, & Renfrew, (1993), it was found that waterbitrth leads to less chances of perineal damage. Therefore the research observed that women were in a better place to control their pushing during waterbirth. As noted earlier, no single mode of birth is 100 percent safe. According to Nikodem, (2000), the medical history of a mother should be taken into consideration before settling for waterbirth. RCM (1999) adds that some conditions or complications may result to great risks hence making waterbirth ill advised. RCM (1999) calls for practitioners to get vigilant in order to offer case advice and guidance as failure to do so may endanger the lives of the mother or the child after waterbirth. Particularly, RCM (1999) notes that women who have had a prior cesarean section are more likely to have successful waterbirths. Other signs to watch for during waterbirths include, temperature changes, significant changes in mother’s heart rate, incase of meconium from the baby or feeling of overwhelmingness for the mothers. Other signs as noted separately by Nikodem, (2000) include, an unusually heavy bleeding, feeling of unwell for the mother or the baby. Nikodem, (2000), notes that in a study on 235 women, 234 reported a feeling of easy and relaxation on being in water, this is explained by a reduction of adrenaline excretion which is associated with fear and pain comon in mothers during delivery. According to, Nikodem, (2000) reduced adrenaline production was found to increase chances of lacerations and tears, therefore any factors which controled its productiuon were an aid to safer and comfortable delivery. Waterbirth is asssociated with easy of rotation in water, changing positions in the water for mothers is a common way of coping with anxiety and pain, Nikodem, (2000)), therfore waterbirth is regarded as the best place for such. Nikodem, (2000) adds that, the movement allowed in the birth pool is instrumental in the hormanal production of oxytocin therfore leading to more easy in delivery. Contrary to the belief that, the delivery proces is a mothers only affair, Beech, (2000), notes that the baby as well plays a crucial role to make the birth process a success. Although the impact on water on the baby is not yet a well researched subject, McCandlish, & Renfrew,1993) notes that, water can ease the stranous process of exertion for the baby. this exertion. The warm liquid is still familiar to the child and softens light, colors and noises. On increased risks, abuse of oxytocin portents a significant risk to mothers (Nikodem, 2000) although careful oxytocin administration VBAC usually an option. Research has established that labor induction whichever way is done increases chances of uterine rupture (Nikodem, 2000). A study by, Jessiman, & Byers, (2000) reported four to five fold chances of ruptures in labor induction cases. Treatment of uterine ruptures. McCandlish, & Renfrew, (1993) notes that early detection of ruptures is the surest way of managing the condition. Therefore, midwives and other caregivers should watch out for sign such as, fetal distress, abrupt tearing of the uterus wall vaginal bleeding, decrease in uterine contractions as well as the regression of fetus Nikodem, (2000). Once the above-mentioned conditions are observed, preparations need to be done for an emergency, as a delay could be fatal on the part o the child. However McCandlish, & Renfrew,(1993) warns that watching out for the above signs is not sufficient and that uterus wall contraction is not a dependable sign to indicate uterine rupture as it may look normal even when there is a looming danger.Maternal morbidity and mortality. Chances of advanced complications during pregnancy or such as uterine rupture, excessive bleeding, and caesarean section, are all possibilities in VBAC. In an interesting observation, Jessiman, & Byers, (2000) notes that these vary from place to place. The relevance of maternal deaths lies in the fact that it is the sole source of evaluating obstetric care quality (McCandlish, & Renfrew, 1993). According to Garland, and Jones, (2000), maternal morbidity has replaced maternal motartility in generating relevant data into the causes of maternal deaths. To better understand mortality and morbidity, Garland, and Jones, (2000), came up with the following model of pregnancy in good health and death. Source: However the above model has been criticized for not clearly depicting the state of a woman in different conditions and depicting some situations known to be life threatening as being non-life threatening. According to, Garland, and Jones, (2000), life threatening obstetric complications are evaluated based on management practices, clinical signs & symptoms, as well as specific organ systems. On the role of maternal choice, Garland, and Jones, (2000), suggests that, mothers must be given the correct information on the issue of waterbirth. Beech, (2000) adds that, mothers showing interest in waterbirth method have a right to access correct verbal and written information from midwives and other practitioners as well as, in cases demanding so, a copy of policy statement from the maternity. This is aimed at assisting mothers to make decisions in full knowledge of risks and benefits associated with the birth method. Beech, (2000), provides the following as guidelines for use of waterbirth. The decision need to be based on the mother’s informed choice The delivery should not involve systemic sedation The woman pregnancy should be a normal term pregnancy at 37+ weeks The delivery has to be a singleton fetus with cephalic presentation The spontaneous rupture of membranes need to follow in < 24 hours Beech, (2000), adds that there is also a need to put into consideration non-clinical criteria including, availability of professional staff and equipment. About the required equipment, Beake S (1999) notes that the following should be considered: Equipment to be used must meet specifications laid down by the policy governing the organization. Besides, it should be clear the source of water for purposes of minimizing waterborne infections which could result if the pool water is drawn from unauthorized sources. The equipment should comply with government’s safety standards.  Concerning health and safety precautions, Dianne Garland (2003)"recommends that; Existing infection control regulations should be revised to include the use of water during labor and birth. On the pool cleaning, maternity authorities are required to seek experts intervention on cleanliness. Maternal Choice The popularity of waterbirths is on the rise this is probably due to although it is considerably too low as compared to other modes of giving birth (Alderdice, Renfrew, Marchant, Ashurst, Hughes, Berridge, Garcia, 1995). Beake, (1999) notes the benefits associated with waterbirths as relaxation for the mother, reduced pain during contractions, shorter labor periods compared to normal birth, reduced chances of using analgesics, little interruption of the perinea, as well as less episiotomies. In terms of associated complications, Vernom, D., (2005) reports that the following are the factors which cause worry for proponents of waterbirths, unrealistic labor expectations, reduced mobility, chances of infection, as well as the possibility that the baby may end up inhaling water. Barbara, (2005) recommends development of more knowledge in waterbirths through further research. Women have access to a large array of information on birth and often desire the perfect birth. This may have been denied to them with a previous emergency caesarean, and subsequently it can be hugely important for some women to have better understanding of birth, and to be in control with the birth of their next child (Balaskas, 1995). REFERENCE Alderdice F, Renfrew M, Marchant S, Ashurst H, Hughes P, Berridge G, Garcia J (1995) Labor and birth in water in England and Wales: survey report. British Journal of Midwifery 3(7): 376-382 Balaskas, J. (1995). New Active Birth — A Concise Guide to Natural Childbirth, HarperCollins, UK, Barbara, H. (2005)"Gentle Birth Choices", Inner Traditions, USA. Beake S (1999) Water birth: a literature review. MIDIRS Midwifery Digest 9(4): 473-477 Beech B (2000) Waterbirth: time to move forward. AIMS Journal 12(2): 1-2 Brown L (1999) The Tide Has Turned: audit of water birth. British Journal of Midwifery 6(4): 236-43 Burns E and Kitzinger S (2000) Midwifery Guidelines for Use of Water in Labor. Oxford Brookes University: Oxford. Dianne Garland (2003)"Waterbirth: An Attitude to Care,", Books for Midwives PR, UK. Garland D and Jones K (2000): Waterbirth supporting practice with clinical audit. MIDIRS Midwifery Digest 10(3): 333-336 House of Commons Health Committee (1992) Second Report on the Maternity Services (Winterton report). HMSO: London Jessiman C Byers H (2000) The Highland experience: immersion in water. British Journal of Midwifery 8(6): 357-361 Lawrence Beech BA (1996) Water Birth Unplugged: the proceedings of the first International Water Birth Conference. Books for Midwives Press: Cheshire McCandlish R and Renfrew M (1993) Immersion in water during labor and birth: the need for evaluation. Birth 20(2): 79-85 New England Journal of Medicine (July 5, 2001, v345, pages 3-8) Nikodem V (2000) Immersion in water in pregnancy, labor and birth (Cochrane Review). In: The Cochrane Library, Issue 2. Update Software: Oxford RCM (1998) Health and Safety Representatives’ Handbook. RCM: London RCM (1999) Handle With Care: a midwife’s guide to preventing back injury. RCM: London Schorn M, McAllister J, Blanco J (1993) Water immersion and the effect on labor. Journal of Nurse Midwifery 38(6): 336-342 Steer PJ and Deans AC (1995) Labor and birth in water: temperature of pool is important. British Medical Journal 311(7001): 390-1 Tookey P and Gilbert R (1999) Perinatal mortality and morbidity among babies delivered in water: surveillance study and postal survey. British Medical Journal 319(7208): 483-487 UKCC (1992) Scope of Professional Practice. UKCC: London UKCC (1992) Code of Professional Conduct. UKCC: London UKCC (1998) Midwives Rules and Code of Practice. UKCC: London UKCC (1998) Guidelines for records and record keeping. UKCC: London  UKCC (1994) Position Statement - Waterbirth. UKCC: London  Vernom, D., (2005). Having a Great Birth in Australia, Australian College of midwives. Read More