Water immersion for pain management during the first stage of labour

Transcription

1 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 hours may be offered the option of being immersed in water during labour and birth, after commencing the recommended course of intravenous antibiotics Page 1 of 6

2 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. Page 2 of 6

3 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 Page 3 of 6

4 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 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 risk of transmission of pseudomonas 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 C 7. Keep the water as clean as possible using a sieve 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 Page 4 of 6

5 Observations 8. Assess maternal and fetal observations prior to the woman entering the water 9. Maternal temperature must be assessed and recorded hourly 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 11. Fetal heart rate (FHR) monitoring and maternal observations must be performed according to normal guidelines Provides a baseline for continual assessment and excludes any risk factors 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 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 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 15. Encourage the woman to leave the water to urinate 2 hourly 16. The woman must leave the water for a vaginal examinations Analgesia 17. Nitrous oxide and oxygen gas may be used in the bath if required (portable unit available) Emergency Management To prevent dehydration The woman must leave the bath prior to the second stage of labour or when the signs become obvious. 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 Page 5 of 6

6 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 pdf Government of South Australia Department of Health (2007) Policy First stage of labour in water Accessed on 14/4/11 from 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 Southern Health (2009) Clinical Practice Guideline Water birth immersion in water during labour and birth guideline. Accessed on 14/4/11 from _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 The Women s (2006) Clinical Practice Gudielines -Water immersion First stage of labour care of women Accessed on 14/4/11 from ]=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 Reg. Authority: Date Effective: Date Revised: Review Responsibility: Date for Review: Original Author: Midwifery Project Officer, Midwife OH&S Portfolio (2011) Updated by: - Page 6 of 6