ALL INDIA INSTITUTE OF MEDICAL SCIENCES

JODHPUR
COLLEGE OF NURSING

VARIOUS CHILDBIRTH PRACTICES: WATER BIRTH,

POSITION CHANGE ETC

Submitted to: Submitted by:

Mr Himanshu Vyas Farheen Khan
Associate Professor M.Sc. Nursing 1st year
College of nursing College of nursing
AIIMS Jodhpur AIIMS Jodhpur

DATE OF SUBMISSION: 21/January/2021

 VARIOUS CHILD BIRTH PRACTICES

WATER BIRTH

It is the process of giving birth in a tub orpool of warm water. It is also considered
as the gentlest birth. Considered as an alternative way ofgiving birth

PRINCIPLE BEHIND WATER BIRTH

The theory behind this type of giving birthis that the baby has been in the amniotic
sacfor nine months and emerging in a waterenvironment is gentler and less
stressful forboth the mother and the baby. It is also believed that it reduces
stressduring labor and birth which also reducesfetal and maternal complications

History of Water Birth

Laboring in water is used by women formillennia. It is supported by Janet Blaskas.

She isa writer about water births and describes the oral histories of South Pacific
Islanders giving birth in shallow sea water. It is also considered as a recent
development in the Western world. The first water birth that we know about in
Europe was in 1803 in France. During the 1960s, Igos Charkovsky undertook
considerable research into the safety and possible benefits of water birth in Soviet
Union.

In the late 1960s, Frederick Leboyer, French Obstetrician developed the practice of
immersing newly-born infants in warm water to help ease transition from the
womb to theoutside world, and to mitigate the of any birth trauma. Michel Odent,
another French obstetrician ,began using the warm-water birth pool for pain relief
for the mothers. During these trials, some women refused to get out of water to
finish birthing. It lead Odent to research about the benefits for the babies and the
possible problems in such births. By the late 1990s, interest in water birth grew in
UK, Europe and Canada.

Benefits Of Water Birth

1. For the Mother:

2. Water is soothing, calming and relaxing.

3. Water seems to increase woman’s energy.

4. Buoyancy lessens body weight which allows free movement and new
positioning

5. Buoyancy promotes more efficient uterine contractions and better blood

circulation, resulting in better oxygenation of the uterine muscles, less pain for the
mother, and more oxygen for the baby.

6. Immersion in water often helps lower high blood pressure caused by anxiety.

7. Water seems to alleviate stress-related hormones, allowing the mother’s body to

produce endorphins, which are pain-inhibitors.

8. Water causes the perineum to become more elastic and relaxed, which reduces
the incidence and severity of tearing and the need for an episiotomy and stitches.

9. As the laboring woman relaxes physically she is able to relax mentally,

concentrating her efforts inward on the birth process.

10.The water provides a sense of privacy, which releases inhibitions, anxiety, and
fears.

Benefits For the Baby

1. Provides a similar environment as the amniotic sac.

2. Eases the stress of the birth, providing reassurance and security.
3. It is also believed that water babies are cries less and are calmer and more
alert

Risks Of Water Birth

1. Theoretical risk of water embolism, which is when the water enters the
mother’s blood stream.
2. Water Aspiration – inhaling water but babies doesn’t actually inhale “air”
until they’re exposed to it.
3. Infections – if the water is not clean

Contraindication of water birth

1. Having multiple births.

2. Herpes infection
 3. Baby is breech
4. Preterm labor is expected
5. Severe meconium or bleeding
6. Toxemia or preeclampsia
7. Meconium-earliest stools of an infant
8. Toxemia-pregnancy induced high blood pressure

INTRODUCTION TO LABOUR AND BIRTHING POSITIONS

The best position for women to adopt during labour and birth varies depending on
which stage of labour she is in.

There are 4 stages of labour.

The first stage of labour is from the beginning of the contractions that cause the
cervix (the opening of the womb) to open (dilate), until the cervix is fully dilated.

The second stage is when the cervix is fully dilated and the woman can start
pushing the baby out.

The third stage is after the baby has been born, and the placenta is delivered.

1. FIRST STAGE OF LABOR

a. Upright positions and keep moving
Women who go through the first stage in an upright position are less
likely to require an epidural. Some studies have found that for women
without epidurals, walking around or being seated upright (e.g. on a
birthing ball) may shorten the first stage of labour by approximately one
hour, although these findings have not been consistent. The shortened
labour is likely due to the increased pressure of the baby’s head on the
cervix, causing it to dilate.
Spending at least 30 minutes during labour in four-point kneeling,
possibly with pillows under the knees and hands, has been found to
reduce persistent back pain during labour. However, this position does
not help the baby to rotate from a posterior position (where the baby’s
face is toward the front of a woman’s body when it is delivered, which
 can be more difficult) to an anterior position (where the baby’s face is
toward the back of the woman’s body when it is delivered), or affect the
need for caesarean delivery, rates of perineal tears, Apgar scores (which
measure the wellbeing of the baby when it is born), or length of labour.
Nevertheless, most women find it an acceptable position for labouring.
Moving around, sitting in a chair or on a ball, showering and baths may
also reduce discomfort during contractions. Being seated in an upright
position during cervical dilation from 6 to 8 centimetres results in less
back pain than lying on the back. Walking around has not been found to
alter the need for augmentation, use of painkillers, or requirement for
assisted or caesarean delivery.
The appropriateness of such activities varies depending on factors such as
the need to monitor the mother and baby, personal preference, and
epidural anaesthesia.As there is no significant effect of posture on labour
progress, women will be encouraged to assume the position in which they
are most comfortable, and as long as there are no complications, women
should be free to walk around if they so wish.
Once labour is well established, the strength of contractions may be such
that moving around becomes more difficult. The midwife and birth
attendant will help the woman find a position in which she feels
comfortable. The woman should be supported by attendants, pillows,
furniture and the like, in order to allow her to relax as much as possible.
Bent knees allow pelvic rocking to take place, and reduce strain on the
joints, while legs wide apart increase the base of support, and allow an
‘open’ pelvic position

b. Non upright positions

Side-lying, supine (lying on the back) or semi-reclining positions are
often preferred by medical staff, as it is more convenient for the staff and
allows easier monitoring of the progression of labour and the status of the
woman and baby. However, some centres have portable monitors that
allow the woman to move around. Attachments such as epidurals and IV
fluid therapy may also limit movement.
When a pregnant woman is lying on her back, the weight of the baby and
uterus presses on the large blood vessels in the abdomen, which may
 reduce the blood supply to the baby and uterus, and decrease the strength
of the contractions. Putting a wedge under one hip can help reduce this
effect. Little is known about the effect of upright versus lying down
positions during the first stage on outcomes for babies or satisfaction for
mothers. In general, the woman should do whatever makes her feel most
comfortable during the first stage, although she will need to take into
account advice from her doctor or midwife regarding her and her child’s
wellbeing, and the need for close monitoring.
Although some women with epidural anaesthesia are able to walk around
safely, if a woman has an epidural or spinal anaesthetic that has resulted
in muscle weakness or problems with blood pressure, she will not be able
to move around until it wears off. If the epidural has partly blocked
feeling, but not movement, the woman may still be able to remain mobile
and upright.
Lying flat on the back (supine) will reduce a pregnant woman’s blood
supply to her baby, and studies have found that less oxygen reaches the
baby as a result. Side-lying or a half-lying positioning with pillows or a
wedge under one hip will improve blood supply to the baby.
During the transition phase, standing or sitting in the shower with water
directed towards the back or the abdomen may help with pain control.
Two-point or four-point kneeling, with the woman well supported on a
beanbag or pillows, may also assist with this stage. If a premature urge to
push occurs, the knee–chest position has been suggested. This is where
the woman kneels with her forehead and arms on the floor and her
bottom in the air, in order to reduce pressure on her cervix

c. Water immersion
Being immersed in water such as a bath or birth pool during the first
stage of labour significantly reduces perception of pain and use of
epidural analgesia. It does not have any negative effects on length of
labour, operative delivery rates, or wellbeing of the baby

d. Positions for first stage

Common options for positions to try during the first stage of labour
include:
Upright positions

Standing: Leaning onto a benchtop or similar surface, or the back of a

chair, or leaning on a partner with hands around their neck or waist for
contractions may be helpful. Some women find asymmetrical positions
reduce discomfort, such as having one leg bent with the foot on a stool;

Sitting, usually with the legs wide apart, leaning forward with elbows on
thighs. Alternatively, straddling a chair, resting forward on pillows on the
backrest, may be helpful, especially to relieve back pain. Again,
asymmetrical positions may be helpful, with one leg up on the lounge
and the other on the floor. Rocking chairs, or swaying with the bottom on
a large ball, may provide comfort;

Kneeling, possibly with a pillow between the bottom and the feet, and
leaning forwards onto a bed (hospital beds may have the head raised to
lean against), beanbag or chair seat;

Walking around, although it is important that the woman conserves her

energy, so taking rests regularly are encouraged.

Non-upright positions

Four-point kneeling, in which the abdomen is hanging freely, and the

hips are over the shoulders. Weight may be taken alternately between the
hands and the forearms resting on a raised surface. This position has been
found to be appropriate for most women with epidural anaesthesia;

Side-lying for rest, with pillows between the legs for comfort; and

Recumbent or semi-recumbent, though the impact on blood supply to

the baby needs to be taken into account.
2. SECOND STAGE OF LABOR

Upright versus non-upright positions for delivery

Many women continue to deliver in a non-upright position, although there is
increasing support for consideration of delivering in an upright position.
Advantages of delivering in an upright position are not proven, but are
thought to include:

-Assistance of gravity helping passage of the baby through the birth canal;
-Decreased compression of the blood vessels in the abdomen, improving the
strength and efficiency of contractions;
-Improved alignment of the baby with the passage through the birth canal,
thus allowing the woman to ‘bear down’ in the direction of the baby’s
movement; and
-Increased width of pelvic outlet

Studies comparing different birth positions are not of good quality.

However, it has been found that for women without epidurals, delivering in
an upright position:

-Is less painful for the woman;

-Is associated with fewer abnormalities in the baby’s heartbeat;
-Results in slightly earlier delivery than non-upright positions;
-Reduces the likelihood of assisted delivery with forceps and episiotomy;
-Increases blood loss from the mother, though this finding may be related to
the increased ease of collection of blood in an upright position; and
-Increases the rate and severity of perineal tears.

Positions for second stage

Examples of positions that may be assumed for second stage include:

Upright positions

a. Partial sitting / half-lying: Trunk tilted backwards approximately thirty

decrees to the vertical. Pillows may be behind the knees, arms and back.
 During contractions, the woman may brace by holding her knees and
pulling up. The partner may sit behind the woman to assist with pulling
her knees up. The benefit of the semi-sitting position is that the perineum
can be easily visualised and is accessible if necessary, though in one
study this position was associated with an increased risk of perineal tears;
b. Sitting, such as on a toilet or birth stool, with the legs wide apart and
leaning forwards with the arms supported on the thighs, or by a partner;
c. Kneeling, on the bed or floor, leaning against a large pile of pillows, or
supported by a partner. Some women may feel more comfortable with
one knee up; or
d. Squatting, supported by partner behind, or holding onto a bar. The
woman should stand to rest between contractions. This may not be
appropriate for women who have had epidurals.

Non-upright positions

a. Lying on the side, also known as the lateral, or ‘Sims’ position, with an
attendant supporting the top leg. This is a good position when delivery is
rapid, as it is gravity-neutral;
b. Four-point kneeling, which may reduce the effect of gravity on delivery
as the head is crowning, reducing the risk of perineal tears, and be more
comfortable for women who are experiencing significant back pain
Women’s Choice of Positions during Labour: Return to the
Past or a Modern Way to Give Birth?
Background. Childbirth medicalization has reduced the parturient’s opportunity to
labour and deliver in a spontaneous position, constricting her to assume the
recumbent one. The aim of the study was to compare recumbent and alternative
positions in terms of labour process, type of delivery, neonatal wellbeing, and
intrapartum fetal head rotation. 

Methods. We conducted an observational cohort study on women at pregnancy

term. Primiparous women with physiological pregnancies and single cephalic
fetuses were eligible for the study. We considered data about maternal-general
characteristics, labour process, type of delivery, and neonatal wellbeing at birth.
Patients were divided into two groups: Group-A if they spent more than 50% of
labour in a recumbent position and Group-B when in alternative ones. 

Results. 225 women were recruited (69 in Group-A and 156 in Group-B). We
found significant differences between the groups in terms of labour length,
Numeric Rating Scale score and analgesia request rate, type of delivery, need of
episiotomy, and fetal occiput rotation. No differences were found in terms of
neonatal outcomes. 

Conclusion. Alternative maternal positioning may positively influence labour

process reducing maternal pain, operative vaginal delivery, caesarean section, and
episiotomy rate. Women should be encouraged to move and deliver in the most
comfortable position
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