Maria is a primigravida woman who wants to have a water birth but she is concerned about neonatal safety in the water, as she has heard and read different stories and opinions about it. She is willing for a water birth as long as the risks for the baby and herself are low or minimal. In this case, the student midwife is going to empower Maria in making her choice by providing up-to-date information about water birth and possible alternatives. So therefore, Maria is able to make an informed decision.

The use of water during labour was officially accepted in 1993 along with the publication of the Changing Childbirth report (Department of Health (DH), 1993) and the recommendations of a birth pool in every UK maternity unit. In 1994, The Royal College of Midwives (RCM) and the United Kingdom Central Council for Nursing, Midwifery and Health (UKCCNMH) published a joint statement about the role of the midwife in the use of water in labour (RCM, 1994; UKCCNMH, 1994). The use of water for labour or birth is part of the nursing and midwifery standards (Nursing and Midwifery Council (NMC), 2010; RCM, 2012) and a policy in the National Service Framework for Children, Young People and Maternity Service (Sloper & Statham, 2004). Therefore, as professionals of health, water birth should be an option available for every woman.

The majority of the evidence available is based on observational, retro and prospective studies (Garland & Jones, 1997; Henderson et al., 2014; Liu et al., 2014; Lukasse et al., 2014; Ohlsson et al., 2001). This could lead to the impression that the acceptability of evidence may be flawed or may be biased (Bond, 2010). The randomised controlled trials (RCT) eliminates these cofounders yet it may be seen negative from women and midwives as water birth is a maternal choice and the study would take that option away. Despite the fact of lack of RCTs, several studies have confirmed the many advantages of the use of water during labour and childbirth, not only as relaxation and pain relief (Garland & Jones, 2000) but as well as decreasing the use of epidural, spinals and episiotomies, upright positions, hands off, shorter first and second stage, increase of physiological third stage of labour and decrease number of caesarean section (Bond, 2010; Henderson et al., 2014; Liu et al., 2014; Lukasse et al., 2014). At this moment, the water immersion is approved and encourage in the Standards for Maternity Care  with the participation of the Royal College of Obstetricians and Gynaecologists (RCOG), the RCM, the Royal College of Anaesthetists (RCA) and the Royal College of Paediatrics and Child Health (RCPCH) (RCOG, 2008). Furthermore, in terms of safety, water seems a safer environment for the mother and the neonate as statistics show that babies born in water have better Apgar score (>7) at 5 min than those who are born “in land”, fewer transfer to neonatal unit and reduced perinatal mortality (American Association of Birth Centers (AABC), 2014; Harper, 2014).

Currently, the incidence of neonatal infection due to the use of water during labour or at birth is as much or possibly less than land birth (Bodner et al., 2002; Cluett & Burns, 2009, 2013; Cluett et al., 2004; Nutter et al., 2014). There have been some cases where there are neonatal infections after birth in water (Franzin et al., 2001; Nagai et al., 2003). The most recent case reported is in 2014 (Fritschel et al., 2015) but it was found in the case report that they used a recreational jetted tub with a recirculated heated water (37ºC).It was used for a period of 48 hours and they used a non-approved chemical by the Food and Drug administration, and the midwifery centre did not have a cleaning/disinfecting policy. Hence, due to many factors, it may not be possible to say that the infection was acquired because of the birth in the water, but it could be related to the use of inappropriate equipment and disinfectant products. A similar case occurred in 2014 in England, where a neonate acquired Legionella after a water birth (Phin et al., 2014). They do not disclose information about the case however, due to this incidence the Health and Safety Executive (HSE) responded accordingly with the current evidence available; no recirculate heated water for prolonged period as at that temperature is ideal for pathogens to grow, and also 10-20% of UK houses’ pipes contains legionella, so they recommend not to use the household water supply. Moreover, some birth pools have a pipe system which it may be difficult to disinfect and a biofilm may remain after disinfection (Phin et al., 2014).

Currently, there is no European guideline or procedure as the incidence is really low, last case reported was more than ten years ago  but HSE recommends if a baby is born in water and is ill before 14 days, it should be screened for Legionella (Phin et al., 2014). Thoeni (2005) took 250 samples from water birth and analysed for bacteria with the following results: 12% Legionella pneumophilia, 11% Pseudomonas aeruginosa, 19% Enterococcus species, 21% Coliforms and 10% Escherichia coli. This brings up the importance of disinfection before and after a water birth. However, in Thoeni’s study it was found that regardless the presence of bacteria in the water, the incidence rate of infection was lower in water than in land (1.22% vs 2.64% respectively). This correspond with similar studies (Cluett & Burns, 2009, 2013; Cluett et al., 2004). Although, McCoy (2012) argues that the samples may be handled inefficiently. McCoy’s study suggests that samples analysed on the same day had more false negatives than if they were analysed the following day. This is because several factors such as the temperature of the samples, the cooling process and the sample holding time. Moreover, Yaradou (2007) suggests that PCR tests are 4.5 higher more accurate than routine cultures, which McCoy could test in his samples. This could mean that samples taken in hospital for culture may be given a high number of false negative and consequently the start of the appropriate treatment is delayed. Appropriate handling of the sample and proper procedure for testing may have a significant impact on the treatment and neonatal outcomes.

For Maria’s reassurance, the student midwife explained the Local trust procedure about cleaning the birthing pool, at this moment it was not possible to show Maria the local trust policy but she seemed relieved  that there was a policy with specific instructions for cleaning and disinfecting plumbing in the birth pools and portable ones (Rogers et al., 2016). Also, it was discussed that in the case of faecal material in the pool, the midwife will “fish it” with a strainer. In case of diarrhoea or too many faecal material, the Local trust advises not to use the birthing pool (Archibald, 2016; Lakin et al., 2014) for the increase risk of infection of E. coli (Rogers et al., 2016) a normal bacteria in the bowels (Campbell, 2014; Macdonald, 2011; Marshall & Raynor, 2014). The National Institute for Health and Excellent Care (NICE) (2014) guidelines says there is insufficient high quality evidence to support or discourage giving birth in water. As a result, despite the fact of the evidence available of low neonatal risk infection, it seems that current national practice has many conditioners for the use of water in labour.

Despite the many benefits of water birth, it has been associated with adverse outcomes as well. Some of them include: Risk of premature gasping and water inhalation by the neonate, fetal hyperthermia, maternal and neonatal sepsis, snapped umbilical cord, shoulder dystocia (Chapman & Charles, 2013) and increase number of perineal tears (Poder & Larivière, 2014).

First of all, it is not recommended to get into the birth pool within 2 hours of opioid administration or if feeling dizzy (NICE, 2014). Both woman and midwife should be safe. This is a precaution in case of collapse or fainting inside the pool. In the rare case of collapse inside the pool, there is a protocol for this situation (Rogers et al., 2016). Maximum temperature of the water is 37.5ºC, this is to prevent fetal hyperthermia which may cause tachycardia and consequently distress the fetus. Another factor to consider is the increased risk of perineal tears in water compared to land birth (Garland & Jones, 1997; Poder & Larivière, 2014; Woodward & Kelly, 2004) . This may be related to general opinion of hands off while the woman is in water for possible stimulation of the neonate and risk of water aspiration (Lumsden & Holmes, 2010) with the subsequent increase of neonatal infection. Although, Dahlen and partners (2013) conducted a large study for more than 12 years in which she compares the incidence of perineal trauma on water birth against six positions in land. She concludes that there is lower perineal tear in water than in land. However, there is not mention whether support on the perineum was applied or not. This could potentially dispute the viability of her study as there are evidences which suggests that hand poised reduces the perineal tear and pain (Foroughipour et al., 2011) and other studies suggest further research is needed as the results are inconclusive (Bulchandani et al.,  2015; de Souza Caroci da Costa & Gonzalez-Riesco, 2006).

Another concern is the shoulder dystocia, which is known as a cephalo-pelvic index disproportion. It has an increased risk in larger fetus (macrosomia), maternal high BMI (overweight and obese women) and maternal diabetes, although the majority of cases occur in normal weight babies, 48% of shoulder dystocia where on normo-weight women (Baskett & Allen, 1995; Chapman & Charles, 2013). So, it seems less plausible that shoulder dystocia is linked to water birth when it is largely unpredictable, unpreventable and only 16% of shoulder dystocia cases were predicted by risk factors (RCOG, 2012).

Although it is unpredictable, there are methods in place to promptly identify any increase risk factor for a shoulder dystocia in the antenatal period. These methods are; measurement of the fundus height during the midwife appointment (NICE), 2008), clinical tests if any maternal risk factors such, as the O’Sullivan Test for Gestational Diabetes which can cause macrosomia and therefore an increased risk of shoulder dystocia and ultimately, an ultrasound scan which can provide an estimated fetal weight (NICE), 2015).

During labour, signs of shoulder dystocia are recognised by slow progress in first and second stage, failure of restitution, fetal head retracts against the perineum (turtling or bobbing) and/or difficulty in achieving crowning (RCOG, 2012; Tiran, 2012). In case of a shoulder dystocia in labour, different manoeuvres are available to manage the situation, McRobert´s, Rubin I, Rubin II, Woodscreew and reverse Woodscreew are some of the techniques that could be used. As a result, it seems that the shoulder dystocia is unpredictable. Adequate antenatal care and highly skilled professionals may reduce/act promptly in case a shoulder dystocia occurs.

Since Changing Childbirth (DH, 1993) the focus has been in a woman-centred care in maternity services, by promoting and highlighting the shared decision making along with a policy of “No decision about me without me” throughout the NHS (Coulter & Collins, 2012). This method has predisposed the ability of midwives to deliver woman-centred care and be part of the decision-making process (Leap, 2009). Woman-centred care gives us a robust midwifery philosophy in which women are encouraged and empowered to exercise their informed choice. This correlates with the meaning and the role of the midwife, “being with woman”. Surveys and qualitative research show the impact that choice and external control have on the birth experience (Cook & Loomis, 2012).

The NMC code encompasses the basics of informed choice, practice in line with the best update unbiased-evidence, communicate clearly and respect people’s right (NMC), 2015), only in a life-saving emergency situation where a woman may be unable to give consent, decision should be made and involve her in the best interest, so that her autonomy is respected (Birthrights, 2013). Although, the reality is completely different. Challenges and obstacles such as, staff shortages, overload workload and time constriction create tension and affects in one way or another at the time of share decision making and true informed choice (Kirkham, 2004, 2010; Levy, 1999, 2006). Risks, benefits and alternatives must be discussed with the woman with the aim that at the end of the session she understands information given and she is capable of making a decision.

This can help to support the woman-centred care, promote for a normal physiological birth and reduce interventions. However, it is essential for a real informed choice and authentic consent process for the woman, to balance the information given, as too much information may confuse the woman and not enough may not enable her to make a decision. Levy (1999) describes that providing too much information, many women find too difficult to manage and will ignore it or stop seeking more information. Furthermore, women may feel overwhelmed by the information and its lack of knowledge and they may prefer to on rely the decision of the “experts” in the area (Carolan, 2005; Hirst & Hewison, 1998). This could arise a conflict with the health professional as sometimes, women want the information and the right to choose but not to take the risk of a decision. This is a great responsibility which makes them feel stressed, loss of control and anxious (Aune & Möller, 2012). As a consequence, it may be found women who transfer their “power” of decision and responsibility on the midwives, seeking for the security and well-being for mother and baby.

To enable women to make their own decision, they need to feel confident, positive, have self-esteem, being able to make a change, access to information and learning skills from improvement (Thomas & Velthouse, 1990) and to do so, they need to feel empowered. As part of the model of women-centre care, midwives are facilitators, guides and a person “with the women”. It is their role to support and enhance them but at the end it is the woman who has to take the initiative.  Leap (2009 p14) states that “One person cannot empower another but an individual can be involved in facilitating situations that enable empower to be taken up by another person. By its very nature, power is not given but taken”. This means that with sufficient information the woman is enabled to make decisions in partnership with the midwives (Carolan & Hodnett, 2007)

To empower women, they first need to build a relationship with the midwife. Today, the midwife-woman relationship is seen as the cornerstone of woman-centred care, which in turn is seen as satisfying for women. Kennedy (2004) considers this relationship to provide the very optimal environment of care to meet women’s needs and the partnership between the midwife and woman is seen as crucial. This relationship aims to facilitate confidence building and to empower woman to trust her own body, to take some control of her baby’s birth, be participate in her care and make decisions  (Kirkham, 2000; Sharpe, 2004). As a result, working in partnership with women is prominently advised.

However, Sharpe (2004) critiques the relationship from the perspectives of both sides. She found that sometimes the woman-midwife relationship did not always occur. Sharpe recognises that the relationship was more powerful when both sides share same philosophical values than those with differences. Moreover,  Freeman (2004) found that although the power between women and midwives were not equal, this did not necessarily affect the progress of the partnership. This corresponds with Harrison and partners (2003) research, he found that some women preferred passive rather than active involvement and used the process of trusting in the expertise professional rather than being responsible for decisions. So, it seems that although the midwife-woman relationship is prominently advised, the evidence suggests that what women particularly want is an opportunity to participate in decision-making and being in control of their pregnancy.

Consequently, Susana has been provided with the best updated evidence related to her concerns and being sure she understands it, supported by the health professional and encouraged in her care.  Ultimately, to make a true informed decision, alternatives must be offered and discuss their advantages and disadvantages. As a result, this will provide to Susana a wide range of options and it will enable her to make her own decision. In Susana´s case, it was discussed that the water may be used only for the first stage of labour or use regular hot showers.

As a conclusion, it could be summarised that women have a right of choice during her pregnancy by national and different bodies’ agreement. The woman-centre care is the cornerstone in maternity services and women should be encouraged in making choices and taking control of their pregnancy. The midwife-woman relationship helps to empower the woman to make decisions and the midwife is the facilitator.

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