Analysing water immersion guidelines

I recently read the most fascinating paper. Called A critical analysis of Australian policies and guidelines for water immersion during labour and birth’, it aimed “to determine how water immersion policies and/or guidelines are informed, who interprets the evidence to inform policies/guidelines and to what extent the policy/guideline facilitates the option for labour and birth.” (Cooper et al 2017).

In order to do this, the authors analysed 25 different policies and guidelines relating to water immersion during labour and birth and, while I wasn’t wholly suprised at what they found, I was impressed by the way in which they have explained how the dominant technocratic approach to birth uses the ideas of risk and safety to limit the options that are available to women using the example of water immersion. Furthermore, their paper offers a great explanation of how midwives are often stuck between the proverbial rock and hard place when it comes to supporting women in this area.

“[W]hilst there were references to women being able to exercise discretion and to request water immersion this was often superficial and overshadowed in part by foci of risk and safety. Autonomous midwifery could only be exercised within the confines of what was risk free and safe which left somewhat of a contradiction given that statements and references to the practice of water immersion. Whilst the documents suggested that [water immersion] was an effective strategy for promoting normality and reducing pain the practice was clearly clouded by a level of uncertainty particularly in regards to maternal and neonatal safety…” (Cooper et al 2017).

The authors noted that the policies and guidelines presented pregnancy and birth as risky events which become even more risky once a woman enters the water, which in turn led to “discussion of the way in which women needed to be continually monitored, observed and assessed for risk” (Cooper et al 2017).

(It really does make one wonder how on earth the human race survived before the era of risk management and mass obstetric intervention 😉 ).

Some waterbirth guidelines, as readers will probably know, are really quite unhelpful, and some of the alleged risks that they cite are unfounded. For instance, “Three documents also included the recommendation that third stage was conducted out of water due to the ‘theoretical risk of water embolism,’ without the support of contemporary evidence.” (Cooper et al 2017). If you don’t know why that is unfounded, this blog post will help.

While some people may feel that papers like this one make depressing reading (and of course they do, in that they highlight the way in which often baseless ideas still dominate maternity care, which can lead to very real problems for women, families, midwives and birth folk). But I also always feel heartened when I read papers such as this one, because they highlight the problem and help us understand that the dominant narrative is only one way of thinking. The technocratic approach to birth is only one viewpoint. It’s not infallible, it won’t last forever, we don’t have to subscribe to it and, no matter how many times people use the words ‘evidence’ or evidence-based’, it doesn’t necessarily make what they are saying or writing any more true or useful.

Cooper M, McCutcheon H, Warland J (2017). A critical analysis of Australian policies and guidelines for water immersion during labour and birth. Women and Birth, in press. https://doi.org/10.1016/j.wombi.2017.04.001
photo credit: HoboMama The water helps via photopin (license)

2 comments for “Analysing water immersion guidelines

  1. Vera Berard
    July 10, 2017 at 8:45 pm

    Let’s at least have consistency in an evidence based, risk management approach. Given the evidence that water immersion provides women in active labor pain relief, the strangest logic is researches and providers alike overlooking the immense, albeit rare risks of epidual spinal headache, paralysis, stroke and the effects of epidual that are sometimes patchy and take away the option of upright labor and birth.
    I wonder if women in progressive labors with uncomplicated health histories and pregancies were able to make an informed decision about use of an immersion tub or epidural what they would choose? In order to be a real option a woman would need access to an immersion tub on a unit, where she can move around in a multitude of ways to facilitate fetal descent and rotation. How many might value maintaining their mobility and being able to void themselves?
    In my place of work there is yet to be an immersion tub, even though professional portable immersion tubs with little chance of water leakage are available. Concern over water damage and the structural integrity of the hospital floor. Never mind that old water pipes have more chace of bursting and that there are often 5 or more people standing together, or people and equipment in the same place in a labor and birthroom that likely weigh as much and more as an immersion tub containing a woman. Supporting women that desire a physiological labor and birth to reach their goal with equipment and tools that can also save the system money every time a woman successfully meets her goal appears to be low down providers, policy makers and administrators list of priorities. I would hazard a guess that a reason for this push back and strange reasoning maybe monetary.

    Vera Berard RM.
    Midwifery Care North Shore, North Vancouver, Canada

    • July 11, 2017 at 6:01 am

      Absolutely! Your point about the weight is a great one; I might highlight that again, as I have heard it used a number of times in an attempt to justify why a pool can’t be put in a room.

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