While the meta-analysis gave us great information about the water birth, there are some things we still don’t know. These are the areas we need to research next. If you are interested in tackling one of these issues let me know and I can connect you with a research team.
Hands off the baby
The first question I have is if hands off the baby matters. I ask this because hands off the baby is often cited as a way to ensure there is no stimulation to breathe. But that does not mean the mother cannot touch the baby during restitution, or that the midwife cannot check for the cord. Sometimes women can’t help but touch the baby. Does this matter? Does this stimulate the baby and cause the first breathe before the baby is taken out of the water? Midwives do check for a nuchal cord, is this necessary or helpful? How much touching can we do and still call it hands off the baby?
Who is eligible
Yesterday I showed you that restricting the analysis to the most rigorous eligibility guidelines did not change the results of the analysis – and we don’t know if that is because everyone was basically doing the same thing but didn’t report it, or if we are too restrictive in who we admit that we let be in the water. Because of this, we need some studies that find out if TOLAC is more successful – or equally successful – if the women are encouraged to spend time in the water.
We need some facilities to start working on the list of specific conditions that restrict a woman from using water during labor – and this is going to be hard work, the reason we say “pregnancy complications” instead of listing them is because then we don’t have to do the hard work of deciding what counts and doesn’t count. I have a suspicion that we are too quick to exclude a woman from hydrotherapy and this means we have less “demand” for our tubs, so we are less able to demonstrate a value to the program. And this means women who might otherwise avoid an epidural or augmentation are prevented from having that benefit.
What is “water birth”
We need to figure out what is “essential” in the package of care that is hydrotherapy. When I say ‘package of care’ I mean all those other things we do because the woman is in water. Things like having the mother upright; continuous support; increasing intake to maintain hydration; immediate skin to skin contact. It may include hands off the perineum, delayed cord clamping, and intermittent monitoring. All of these things are part of the care of a water birth, and we need to be careful that when we implement this intervention in the US, we are using the full intervention – and not just having nurses fill tubs and leaving the women to sort it out.
With active management labor, the only piece that was implemented in US facilities was the oxytocin – the part that worked best was the continuous presence of a support person. So our version of implementing active management of labor was successful for some things and messed up others. I recently read an evaluation from an implementation of a low dose oxytocin protocol – the hospital had changed the protocol and were dutifully tracking the rate of uterine hyperstimulation and CD for fetal distress; these of course were decreased. But the CD rate didn’t decrease, something was taking its place — it was CD for failure to progress (and chorioamnionitis). The hospital had assumed that if you just change the speed at which we give oxytocin that changes our “package” of care; but they never changed eligibility for an induction, they never changed the guidelines for assessing progress in labor so they never made the other changes that create a “package” of how we do induction at this facility.
We need to know what must be included for the benefits of waterbirth to occur – as we know from the literature the benefits don’t always show; there is still disagreement about perineal integrity.
We need to understand the costs of having a tub program – because this is a big deal if you want a program in your facility. A facility must either add tubs to a renovation plan or purchase portable tubs. Getting administrative approval for either of these requires evidence about the initial costs, the ongoing costs, and the benefit to the hospital because of the tubs.
We do have one study that looked at the cost-effectiveness of hydrotherapy for maternal wellness – which they described as perineal integrity. They found water birth was a cost effective method. But we can do more, because there are additional benefits to hydrotherapy that should be investigated.
If we really want to expand hydrotherapy in labor, we to make estimations about how many women will use the tubs – and if you are not going to put them in every room, you might need to estimate duration of use, so you get enough tubs. Right now, the evidence is that you might have anywhere from less than 5% to over 60% of women using the tubs. That is too wide a variation for any of us to plan accordingly.
Starting a hydrotherapy program takes more than just installing tubs. We need some implementation projects to describe training for new midwives and nurses to use hydrotherapy and successful development of a program. We need this because midwives have an initial reluctance and a steep learning curve, and need time with initial supervision to build their confidence and acceptance of water birth. We also need some better evidence about appropriate informed consent practices; nurses and midwives should not feel they cannot offer hydrotherapy because it will take too long before they can begin to fill the tub.
As you can see, we’ve got a lot of work to do to help hospitals build successful hydrotherapy programs. Let me know if you want to be part of a research project.