Hydrotherapy:

• Definition: Hydrotherapy is the application of water for the

treatment of physical or psychological dysfunction.
• Warm water immersion: Immersion in a tub with depth that
allows for complete submersion of the
abdomen to the breast level.
• Water labor: Use of warm water immersion during any stage of
labor up to but not including the birth of the neonate.
• Water birth: Use of warm water immersion during the second
stage of labor that results in the birth of a neonate entirely
underwater, regardless of the location of delivery of the placenta.
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Eligibility criteria:
• Women who meet the following criteria are eligible to use warm
water immersion during labor and/or birth:
• Cephalic presentation.
• Singleton.
• 37 weeks gestation or greater.
• Baseline fetal heart rate and regular rhythm.
Contraindication:
• Abnormal vaginal bleeding.
• Maternal fever > 38o C (100.4o F)
• Any condition that requires continuous fetal monitoring.
• Active herpes simplex lesion, hepatitis B or C, HIV.
• Epidural analgesia or anesthesia.
• Intrapartum hemorrhage.
• Pregnancy complications or conditions that can complicate birth or
transition of the neonate to extrauterine life.
• Administration of opioid or other sedating medications within one
hour of hydrotherapy initiation or longer in case of persistent risk to
maternal mobility, airway protection or abnility to follow instruction.
MANAGEMENT OF LABOR IN
• Before immersion make sure that the women is the right candidate for
WATER:
warm water immersion based on inclusion and exclusion criteria.
• The tub should be filled with ordinary tub water without additives.
• The water temperature should be assessed hourly
• 1. During the first stage of labor in water the water temperature should
never exceed 37.5 c.
• The women in labor may enter or leave the water at any point with
assistance.
• Record the times that the women enters and leaves the pool.
• If complications or changes occur in the maternal or fetal condition that
requires further assessment or treatment outside the tub.
• Positioning for comfort in the tub is dependent on the preferences of the
women.
• Provide hydration in the form of oral fluids or IV fluids as necessary. All
lines should be covered with occlusive water resistant dressing while
IV
women
the is in the tub.
• The well being of the women and fetus are assessed and managed in
accordance with practice protocols for any other women in labor
including monitoring maternal vital signs, assessing the fetal heart
rate, maternal position changes and IV fluid bolus for fetal heart
rate changes etc.
• Vaginal examination may be performed underwater when necessary.
• Intermittent maternal self administration of nitrous oxide during labor
and birth in water is acceptable when available.
Management of the Second Stage of Labor:
• The women may choose any position in the tub for pushing during the
second stage of labor that feels comfortable and safe for her.
• During the second stage of labor the water temperature should never
exceed 37.7 and may be adjusted based on the women’s preference within
a narrow range of 36.1 to 37.7.
• Maternal and fetal well being should be assessed and documented.
• Fetal heart rate and contractions pattern are assessed in accordance with
the standard of care.
• The neonate should be born completely underwater without exposure to
air until the face is brought gently and directly to the surface. The
neonates head must not be re-submerged under water after it has been
brought to the surface.
• If the women raises herself out of the water and exposes the head of
fetus to air, she should be assisted or supported to remain out of the water
the
to avoid the potential risk of the neonatal gasping underwater with re-
submersion.
• After birth, assist in bringing the neonate directly and gently to the
surface within (5-10) seconds to minimize tenion on the umbilical
cord and to reduce the possibility of avulsion.
• Maintain warmth of the neonate through skin-to-skin contact with
the women and submersion of the neonate’s lower extremities,
abdomen and chest. Dry the neonates exposed head to reduce
heat loss.
• Apgar score should be obtained at one and 5 minutes after birth per
noutine.
 Third stage of
•labor:
Can occur in or out of the tub depending on the status of the woman
and neonate.
• If the health care providers note increase in bleeding, the women
should be immediately removed from the tub for continued
evaluation and treatment.
• Evaluation and repair of perineal lacerations are ideally accomplished
on a bed for optimal visualization.
• Infection control principles:
• Clean the hydrotherapy tub after each use.
• Before cleaning, don non-sterine, single use gloves.
• Drain the hydrotherapy tub, remove all debris from the tub, and
dispose the debris.
• Manually wash all inferior surfaces of the hydrotherapy tub using a
mild non-abrasive detergent solution and clean towel or
disposable cloth.
• Rinse the tub with warm water to remove all detergent residue.
• Apply a disinfecting agent to all surfaces to the hydrotherapy tub
using a spray application and ensure all surfaces are thoroughly
disinfected.
• After achieving appropriate disinfection, rinse the hydrotherapy tub
with hot water to remove the remaining chemical residue and allow
surfaces to air dry.
Precaution:
Performance of infection control measures in accordance with separate
guidelines.
Universal personal protective equipment should be used according to facility
guidelines.
Any break in maternity care professional or patient skin integrity must be
covered with an occlusive waterproof dressing.
Emergency equipment should be readily available in the room with the
laboring women.
If the water becomes contaminated with feces or debris, the women may be
asked to leave the tub temporarily until it is removed or the water can be
changed and the tube cleaned.
Temperature of the tub should be maintained at 37 to 37.5o c.
After each use, the tub and all reusable equipment must be
thoroughly cleaned and allowed to drybefore next use per guidelines.
 Complications
•: Umbilical cord avulsion: (tearing) . This may occur if too
much traction is placed on the cord during water birth.
• Hyperthermia: Elevation of maternal core temperature can result
in maternal hyperthermia, which can lead to fetal tachycardia.
• Perineal laceration: Waterbirth is associated with decreased rate
of third and fourth degree perineal lacerations.
• Infections: in studies of water labor and water birth studies have
not demonstrated increased overall rates of maternal or neonatal
infection following immersion during any stage of labor regardless of
the status of membranes during hydrotherapy. However if the tub
is not cleaned properly or harbors unusual organisms such as
Pseudomonas or Legionella, the women and/or neonate could
acquire an atypical infection.
Complications
• Neonatal water aspiration: Researchers demonstrated that when
: secondary apnea is present (due to fetal hypoxemia), neonates may
exhibit a gasping reflex at the time of waterbirth that can result in the
inhalation of water and potentially make resuscitation and
ventillation more challenging.
• Mortality: As with conventional birth, the potential exists for death
of the woman or neonate.
Benefits:
• Warm water immersion during childbirth provides the women in
labor with alternatives to conventional pain relief strategies and birth
methods.
• Increased mobility.
• Reduced need for analgesia or anesthesia.
• Lower episiotomy rate.
• Decreased likelihood of third and fourth degree perineal lacerations.
• Facilitation of labor progress by the diminishing stress and
catecholamine production which can enhance the perception of pain
and slow the progress of labor.
• Greater levels of patient satisfaction.
Why it is called liquid epidural?
• mothers call it water immersion the "liquid epidural" because of the
immense relief it can offer during birth. Being immersed in water in a
labor tub helps in a few ways:
• Pain relief: Some mothers experience this the instant they step into
the water. Again, it's the liquid epidural!
• Relaxation: Most of us associate a warm bath with relaxation.
Being cushioned by warm water just feels great, which helps your
body relax. During birth, the more you can relax the more smoothly
labor will go and the less pain you will experience.
• Buoyancy: The water counteracts gravity and keeps that baby belly
from weighing you down. It's also much easier and more comfortable
to move around because of this. There are all kinds of great positions
you can be in laboring in the tub.
• A safe space: The labor tub can feel like a cozy little cocoon, safe from
the medical environment around you.