The VBAC waterbirth experience in Fife

Marian Sellar recounts one maternity unit’s experience of waterbirths and emphasises the importance of providing the service that birthing women want.

Midwives magazine:

August/September 2008

The midwife-led unit (MLU) at Forth Park Hospital in Kirkcaldy, Fife was opened in February 1994. It comprises of five rooms (one of which is designated for waterbirths) and is classed as an ‘alongside’ MLU as it is situated within easy reach of the obstetric and neonatal units at Forth Park.

In late 1994, core staff were selected. This group of enthusiastic and motivated midwives were committed to promoting normality in childbirth and after devising our own philosophy and guidelines, we were able to encourage evidence-based practice and also to challenge outdated medical/midwifery notions of ‘normality’.

The birth rate in Fife has steadily increased over the years, as has the amount of women using the MLU – in the first year, we had 750 births out of a total of 3000. It was 2007 that saw our numbers reach over 1500, in effect doubling our numbers in the 14 years since opening -– statistics we are very happy with. Our waterbirth numbers have also gradually increased over the years and this continues to be a very popular choice for women.

In 2005, the MLU was runner-up in the National Childbirth Trust’s ‘Better birth environment’ award – the midwives were very proud to receive this accolade, particularly as the competition was UK-wide, and because we were nominated by the women who have used our service.

In January this year, the MLU received the RCM award for promotion of normality at the College’s annual midwifery awards – an honour which has delighted and inspired us all.

Waterbirth is now a common type of birth on offer throughout the UK and the midwives at Forth Park Hospital have been keen to promote this method since 1990. This article highlights the small amount of women who have come to us for a vaginal birth after caesarean section (VBAC) waterbirth. We believe women are progressively becoming more aware of what is available and they are assured that the midwives will support their choices and help them achieve the birth experience they want.

There is little evidence regarding the availability of VBAC waterbirths in UK maternity units, although the Association for Improvements in the Maternity Services’ (AIMS) Birth after caesarean reports that ‘most independent midwives and some NHS midwives are quite comfortable with the idea’ (2004). The joint statement from the
RCM and RCOG (2006) observes that women with previous caesarean sections (CS) have used water for labour and birth without reported problems.

VBAC waterbirth

In 1996, one of the consultants asked us if we would accept a woman who was keen for a waterbirth. The request was unusual because this woman had had a CS previously and now wanted to have a normal birth experience in water. The consultant had discussed the risk factors with the woman and was pleased to agree with her wishes – as were the midwives. We were delighted at the prospect of providing this woman with the care she wanted and taking on a new challenge. Since that first success, there have been several VBACs in the MLU, some of which have been happy normal waterbirths. Guidelines for these waterbirths are no different from any other, and no cardiotocographic monitoring is offered – in line with our ‘low-risk’ labour philosophy.

To date, there have been 27 VBACs in the MLU, ten of which were waterbirths – small numbers, but an indication of the change in attitudes to women who are challenging the system and succeeding.

This is all the more pertinent this year, when our poster presentation at the International Confederation of Midwives 28th Triennial Congress in Glasgow was under the heading ‘women’s voices’. We have found that women in Fife are certainly becoming more vocal!

Labour duration

Of the 27 VBACs we have had in the MLU, where the mothers have been treated ‘normally’:

• Two had Haig Ferguson forceps delivery (HFFD)

• Two had a Kiwi omnicup vacuum delivery

• One had a ventouse delivery

• Ten have been waterbirths (out of 14 intended waterbirths, two had spontaneous vaginal deliveries out of the pool, one had HFFD, and one had a ventouse delivery)

• None had a repeat CS

• There were no incidents of fetal distress

• The women using the service all gave positive feedback to their midwives about the experience.

As can be seen from the figures in the table below, labour durations are no different from any other normal delivery, as are the perineal trauma rates or the babies’ Apgar scores. 

The positive change in attitude to some women’s need for normal labour after CS is not only welcome, but long overdue. The alongside MLU is ideal for this and women, once well informed, are comfortable in making their decision of where and how to birth their babies, knowing that help will be at hand should they need it.

At present, we have to depend upon the women themselves making a request for a normal, minimal intervention birth in the MLU rather than having a booking system that would provide them with enough information to make a choice they are happy with. This important issue will need to be addressed as it is likely to be the main reason that we see these women so infrequently – the ones we do see are usually those who have made  their wishes known to consultants who are sympathetic to the women’s needs and have confidence in the MLU midwives.

It may well be that NHS midwives are ‘comfortable with the idea’ (Lesley, 2004), but thinking about VBAC waterbirth, and actually providing it are two very different things. I suspect that in many areas of the UK, there would be a great deal of resistance from both management and the medical establishment to this type of care, despite the fact that there are midwives keen to give it.

We have built up a considerable amount of mutual trust with both management and consultants – without this, we would not be able to have the service we do. A good deal of work remains to be done, but we know that we are jointly improving women’s satisfaction with our service, in particular those who have felt disappointed by a previous birth experience.

As long as women are prepared to put their trust in their own bodies’ ability to labour, the MLU midwives will be here to welcome them. Given the ever-rising CS rates and the call for promotion of normality, there may well be plenty of them in the future.

References

Lesley J. (2004) Birth after caesarean. Association for Improvements in the Maternity Services: Surbiton: 40.

RCM/RCOG. (2006) Joint position statement number one: Immersion in water during labour and birth. RCM/RCOG: London.