Reflecting on State Guidelines for Water Birth: Arizona and Texas

11 Dec 2016

Arizona Department of Health Services (USA) published guidelines for waterbirth in November 2016 following two incidents of Legionnaire’s disease in newborns after waterbirth earlier that year.

These guidelines are similar to those adopted by Texas Midwifery Board in June 2015, again developed in response to an incident of Legionnaire’s disease in a newborn. The publication of the “Notes from the Field” article in the Arizona CDC’s Morbidity and Mortality Weekly Report in June 2017 spurred us to go back and compare the two sets of guidelines from our perspective as a birth pool manufacturer. Both sets of guidelines are full of good advice.

Two things stood out:

Body Mechanics of the Attendant On this there is agreement. Both sets of guidelines specifically say “Consider using good body mechanics such as not leaning over the edge of the pool for long periods of time and using kneeling pads when necessary.” At the 2017 ACNM Conference in Chicago, we had several conversations with CNMs raising their concerns about the impact of leaning over the side of our FP3 pool for extended periods of time. Many related that they did this because the mother requested hands-on support during second stage.

Other midwives expressed the view that the pool depth (FP3 Labour & Birth Pool) is one of the deeper permanent installed pools on the US market) was safer for the newborn and they tailored their support for the mother to avoid prolonged periods leaning over the side of the pool. This area of safety is challenging for providers of waterbirth. Midwives and other attendants can avoid excessive risks of body mechanical injury by considering how to effectively support a woman in a pool without leaning over the edge for long periods.

Depth of Water Both guidelines are clear on the need for sufficient depth of water. The Texas guideline states that “...the water must completely cover the

mother’s abdomen, but not reach to the level of her neck.”

The Texas guideline does not refer to the position the mother is in, whereas the Arizona guideline goes further in its definitions: “Water Immersion: A depth of water which ensures the mother’s belly and bottom to be submerged fully in water while she sits or kneels....” We applaud the intent of the Arizona guidelines to be more specific on this. There is room for ambiguity in the definition of “kneels” because an upright kneeling position, with thighs aligned vertically, leads to an increase of 10” +/-3” in the distance from the knees to the top of the abdomen. Our interpretation is that they meant a low kneeling position with the mother’s bottom on her feet: to do otherwise would mean a minimum depth of water of 28” or more.

This would have consequences for the attendant’s ability to access and support a woman in the pool. We expect awareness about body mechanics of attendants and minimum water depth to increase over time as experience with waterbirth grows. The Arizona and Texas waterbirth guidelines are a good step towards high standards of practice and more states will no doubt follow this lead. 

Sources: http://www.azdhs.gov/ documents/licensing/special/midwives/training/guidelines-for-water- immersion-water-birt h.pdf http://www.dshs.texas.gov/midwife/waterbirth/ https://www.cdc.gov/mmwr/volumes/66/wr/mm6622a4.htm