- Email: [email protected]
Strategies for Providing Low-Cost Water Immersion Therapy With Limited Resources
In Practice
Strategies for Providing Low-Cost Water Immersion Therapy With Limited Resources BRENDA BRICKHOUSE CHRISTINE ISAACS MEGHANN BATTEN AMBER PRICE Hydrotherapy During Labor Pain in labor varies greatly among women and can be influenced by physiologic, psychological and social factors (Jones et al., 2012). Water immersion therapy as a nonpharmacologic
Abstract At our university-affiliated medical center, a major renovation of the women’s health and birthing unit resulted in the temporary loss of the permanent tub used for water immersion therapy during labor. Because 40 percent of the women in the nurse-midwifery practice utilize hydrotherapy, we undertook a rigorous search for an interim solution. We developed a safe and cost-effective strategy that can be easily replicated and utilized by others to provide hydrotherapy for laboring women. DOI: 10.1111/1751-486X.12247 Keywords hydrotherapy | labor and birth | pain management in labor | water immersion
526
© 2015, AWHONN
http://nwh.awhonn.org
Photo courtesy of the author
T
The terms “hydrotherapy” and “water immersion” are often used interchangeably. Hydrotherapy can include the use of water in various modalities (e.g., heat packs, cold packs, steam, showers or bathing) for its psychological and physiologic therapeutic effects. For the purposes of this article, hydrotherapy is defined as water immersion with submersion in water deep enough to completely cover a pregnant woman’s abdomen (Cluett & Burns, 2009) during the active phase of labor.
Review of the Evidence A Cochrane review of 12 randomized trials (including 3,243 women) found no evidence of increased adverse maternal, fetal or neonatal effects from laboring in water (Cluett & Burns, 2009). The review noted a significant reduction in epidural, spinal and paracervical analgesia/ anesthesia rates of those women who utilized water immersion during labor as compared to controls (Cluett & Burns, 2009). The authors of one study noted that the first stage of labor was reduced by 32.4 minutes (Cluett, Nikodem, McCandlish, & Burns, 2004). There were no significant differences in assisted vaginal births, cesarean birth rates, use of oxytocin augmentation, perineal trauma or maternal infection (Cluett & Burns, 2009; Young & Kruske, 2012). There were no significant differences in Apgar scores < 7 at 5 minutes (Cluett & Burns, 2009; Dahlen, Dowling, Tracy, Schmied, & Tracy, 2012),
neonatal unit admissions or neonatal infection rates (Cluett & Burns, 2009). Women laboring in water had more freedom of movement (Maude & Foureur, 2007; Stark et al., 2008) and increased uterine contractions (Stark et al., 2008) while reporting decreased pain (DaSilva, DeOliveira, & Nobre, 2009) and increased satisfaction with their birth experience (Cluett & Burns, 2009). In women diagnosed with labor dystocia, water immersion decreased
Immersion into water increases buoyancy, increasing support to the extremities and providing a sense of weightlessness the need for labor augmentation with amniotomy and oxytocin (Cluett, Pickering, Getliffe, & Saunders, 2004). Water immersion was also associated with increased spontaneous vaginal births among nulliparous women (Burns, Boulton, Cluett, Cornelius, & Smith, 2012). Women described water immersion as creating an environment that promoted privacy, relaxation, freedom of movement and the ability to cope with pain (Maude & Foureur, 2007).
Steps to Initiate Water Immersion The certified nurse-midwives (CNMs) at our university medical center use water immersion routinely for labor management, and prior to October 2012 had the availability of a permanent immersion tub. Because 40 percent of the women in the midwifery practice utilized water immersion during labor, months prior to an anticipated renovation of the women’s health and
Box 1.
Hydrotherapy Kit: Supplies and Cost to Individual Item
Cost
½" × 25' hose (lead-free)
$15
Two-pack polymer hose cap
$1
Eco generic pool liner
$30 (ordered online)
Total
$46
December 2015 | January 2016
In Practice
modality for pain management has been utilized for centuries and can be used to safely manage pain in labor (Cluett & Burns, 2009; Garland & Jones, 2000). Immersion into water increases buoyancy, increasing support to the extremities and providing a sense of weightlessness (Stark, Rudell, & Haus, 2008), and decreases anxiety secondary to neuroendocrine response modification of psychophysiological processes (Benefield et al., 2010). Physiologically, the hydrostatic pressure from water immersion moves fluid from the extravascular space into the intravascular space with the potential to reduce blood pressure and edema (Florence & Palmer, 2003). Water immersion may increase uterine perfusion via decreased pressure on the vena cava and improved diuresis due to increased blood flow to the kidneys (Cluett & Burns, 2009).
Brenda Brickhouse, MS, CNM, WHNP-BC, is now retired and was previously a certified nurse-midwife and assistant clinical professor at VCU Medical Center in Richmond, VA. Christine Isaacs, MD, is an associate professor, director of the General Obstetrics & Gynecology Division and medical director of midwifery services at VCU Medical Center in Richmond, VA. Meghann Batten, MS, CNM, is a certified nurse-midwife and assistant clinical professor at VCU Medical Center in Richmond, VA. Amber Price, MSN, CNM, is vice president of the Women & Children’s Service Line at Henrioc Doctors’ Hospital in Richmond, VA. The authors report no conflicts of interest or relevant financial relationships. Address correspondence to: [email protected].
Nursing for Women’s Health
527
birthing unit (which would involve a temporary loss of the permanent tub), the CNMs began developing a strategy to provide uninterrupted access to water immersion for the women in their midwifery practice. Initially, the strategy was to implement the use of one portable tub, but during the renovation, the number of women requesting water immersion increased, so an additional portable tub was added.
Multidisciplinary Commitment
Logistics We had to find a portable immersion tub that the smaller labor rooms
528
Nursing for Women’s Health
Women described water immersion as creating an environment that promoted privacy, relaxation, freedom of movement and the ability to cope with pain (15' × 10.5') would accommodate and that would be suitable for laboring women. The round birthing pools were too large for a small labor room and were logistically impractical. For trial purposes and to test feasibility, we used and later purchased a 100 gallon (378.5 L) stock tank. Without changing the configuration of the labor room and with the removal of a spare chair and bedside table, the “tub” (52" long × 32" wide × 24" deep) fit easily in the smallest labor room. The tub is placed so that door access for moving the bed is not blocked and the site where the infant warmer is placed is uncompromised. Although the tub is compact, it has comfortably accommodated women weighing in excess of 299 lbs and with heights up to 6', while allowing
abdominal submersion and the ability to labor in different positions (see Figures 1 and 2).
Equipment The sink faucets in the labor rooms presented a challenge. Members of the engineering staff removed the aerators from the faucets so that an adapter could be attached to connect the hose to the faucet for filling the tub. With their assistance, we found proper fitting male and female adapters. Two sets of adapters are kept in the tub toolbox, as are a thermometer, wrench, two large clips and duct tape (see Box 2). If necessary, duct tape can be used to attach the hose to the sink faucet. The greatest equipment challenge was finding the correct drainage
Volume 19
Issue 6
Photo courtesy of the author
The first step in the process was a multidisciplinary commitment involving nurses, nurse managers, obstetricians, maternal-fetal medicine physicians, infection control staff (Department of Epidemiology) and members of Plant Operations and Planning (Engineering). Because this was a temporary solution to achieve water immersion, the CNMs assumed the responsibility for filling, draining, cleaning, storing, purchasing and restocking tub supplies. The women’s birthing unit provided reimbursement for expenditures. Also, prior to implementing the official use of the portable tub system, three “tub trials” were completed to ensure real-time feasibility. The system involves individual women making a commitment to supply their own “hydrotherapy kit” for use in labor. Each woman receives a brochure titled Hydrotherapy During Renovations that explains the renovation circumstances, the temporary loss of the permanent tub and the availability of a portable tub. The brochure contains information for creating their personal kit, which includes a list of needed supplies, purchasing information and cost (see Box 1). Women are advised that the supplies are essential for filling and draining the tub, as well as for infection control.
In Practice
Figure 1.
Tub With Liner
Figure 2.
Tub With Pump for Drainage
Photos courtesy of the author.
pump. A utility transfer pump that sits outside the tub, rather than a submersible pump that is placed directly into the tub for draining, was purchased. The utility transfer pump produces more noise than the submersible pump and takes 15 to 20 minutes to drain the tub, but
December 2015 | January 2016
proved to be the most efficient option for water removal.
Guidelines and Procedures Suggested guidelines for water immersion are shown in Box 3 and our medical center’s water
Nursing for Women’s Health
529
immersion procedures are shown in Box 4.
Cleaning and Infection Control In conjunction with our Department of Epidemiology and utilizing the Centers for Disease Control and Prevention’s (CDC) Guidelines for Environmental Infection Control in Health Care Facilities-Hydrotherapy Tanks and Pools (CDC, 2012), we developed cleaning procedures including the type of disinfectant, methods used to clean the tub and related equipment. The tub used in this facility is made of high-density polyethylene, and the manufacturer provides general chemical resistance characteristics of this product online. Per the CDC guidelines, the tub is wiped down inside and out with an Environmental Protection Agency (EPA) registered product as set by our institution facility policy. To clean the utility transfer pump and yellow suction hose, a 10:1 solution of water and sodium hypochlorite is pumped through both. The outside of the pump, the hose attachment fittings on the pump and the yellow suction hose are wiped with an EPA-registered product as set by our institution facility policy. All equipment is cleaned prior to removal from the labor and birthing room.
Box 2.
Hydrotherapy Equipment and Supplies: Cost to Facility 100-Gallon stock tank (high-density polyethylene)
$75
120-Volt transfer utility pump
$82
Canola oil for priming pump
$3
Bleach for cleaning pump (three cases)
$27
8" × 100" Roll clear plastic (for floor covers)
$36
½" × 25' Hose
$15
10 Aqua nets 5" × 16" (less than debris nets)
$26
Craft toolbox
$10
Clip set*
$8
10" Wrench*
$11
Roll of duct tape*
$6
Female aerator adapter × 2*
$12
Male aerator adapter × 2 (furnished by Plant Operations and Planning)* Thermometer (furnished by Plant Operations and Planning)* Nonsterile shoulder length gloves (furnished by birthing unit) Moving dolly (furnished by birthing unit) Total *Items stored in the toolbox.
2009). It is for these reasons that when faced with limitations during a renovation of the women’s health and birthing unit, we had to search for a
The steps developed and detailed here have proven to be an effective, low-cost, practical way to bring water immersion therapy to places with limited resources
Conclusion Research supports that water immersion during labor is an effective nonpharmacologic intervention that promotes relaxation (Benfield et al., 2010), reduces pain and anxiety, increases maternal satisfaction with the childbirth experience and has no increase in adverse maternal, fetal or neonatal outcomes (Cluett & Burns,
530
Nursing for Women’s Health
$301
practical, low-cost solution to maintain water immersion therapy for laboring women. The steps developed and detailed here have proven to be an effective, low-cost, practical way to bring water immersion therapy to places with limited resources (whether due to space, finances or lack of existing infrastructure). These steps can be easily duplicated so that laboring
women have access to safe water immersion options. NWH
Acknowledgments The authors thank VCU Medical Center’s Labor & Delivery staff, as well as members of the Department of Plant Operations & Planning and of the Department of Epidemiology for their assistance in making these efforts successful.
References Benfield, R. D., Hortobagyi, T., Tanner, C. J., Swanson, M., Heitkemper, M. M., & Newton, E. R. (2010). The effects of hydrotherapy on anxiety, pain, neuroendocrine responses, and contraction dynamics during labor. Biological Research for Nursing, 12(1), 28–36. doi:10.1177/1099800410361535 Burns, E. E., Boulton, M. G., Cluett, E., Cornelius, V. R., & Smith, L. A. (2012). Characteristics, interventions, and
Volume 19
Issue 6
In Practice
Box 3.
Suggested Guidelines for Water Immersion PRIOR TO WOMAN ENTERING TUB Normal maternal and fetal surveillance Singleton gestation Cephalic presentation Gestational age ≥ 37 weeks Category 1 tracing The woman has committed to and provides her hydrotherapy supplies as detailed previously
WHILE WOMAN IS IN TUB Maternal and fetal surveillance according to facility policy Intermittent fetal monitoring according to facility policy Continuous electronic fetal monitoring (CEFM) via telemetry for oxytocin induction/augmentation of labor CEFM via telemetry for trial of labor after cesarean
outcomes of women who used a birthing pool: A prospective observational study. Birth, 39(3), 192–202 Centers for Disease Control and Prevention (CDC). (2012). Guidelines for environmental infection control in health care facilities—Hydrotherapy tanks and pools. Atlanta: Author. Retrieved from www.cdc.gov/healthywater/ swimming/pools/hydrotherapy-tank-pooloperation.html Cluett, E. R., & Burns, E. E. (2009). Immersion in water in labour and birth (review). The Cochrane Database of Systematic Reviews, Apr 15(2),CD000111. doi: 10.1002/14651858. CD000111.pub3. Cluett, E. R., Nikodem, V. C., McCandlish, R. E., & Burns, E. E. (2004). Immersion in water in pregnancy, labour and birth. Cochrane Database Systematic Reviews. doi:10. 1002/14651858 Cluett, E. R., Pickering, R. M., Getliffe, K., & Saunders, N. J. (2004). Randomized controlled trial of laboring in water compared with standard of augmentation for management of dystocia in first stage of labour. British Medical Journal, 328, 314–318. doi:10.1136/bmj.37963.606412 Dahlen, H. G., Dowling, H., Tracy, M., Schmied, V., & Tracy S. (2012). Maternal and perinatal outcomes amongst low risk women giving birth in water compared to six birth positions on land. A descriptive cross sectional study in a birth centre over 12 years. Midwifery, 29(7), 759–764. doi:10.1016/j.midw.2012.07.002
December 2015 | January 2016
DaSilva, F. M. B., DeOliveira, S. M. J. V., & Nobre, M. R. C. (2009). A randomized controlled trial evaluating the effect of immersion bath on labour pain. Midwifery, 25(3), 286–294. doi:10.1016/j.midw.2007.04.006 Florence, D. J., & Palmer, D. G. (2003). Therapeutic choices for the discomforts of labor. Journal of Perinatal & Neonatal Nursing, 17, 238–249. Garland, D., & Jones, K. (2000). Waterbirth: Supporting practice with clinical audit. MIDIRS Midwifery Digest, 10(3), 333–336. Jones, L., Othman, M., Doswell, T., Alfirevic, Z., Gates, S., Newburn, M., … Neilson, J. P. (2012). Pain management for women in labor: An overview of systematic reviews. The Cochrane Database of Systematic Reviews, Mar 14(3), CD009234. doi: 10.1002/14651858.CD009234. pub2. Maude, R. M., & Foureur, M. J. (2007). It’s beyond water: Stories of women’s experiences of using water for labour and birth. Women and Birth, 20(1), 17–24. doi:10.1016/j.wombi.2006.10.005 Stark, M. A., Rudell, B., & Haus, G. (2008). Observing position and movement in hydrotherapy: A pilot study. Journal of Obstetric, Gynecologic and Neonatal Nursing, 37(1), 116–122. doi:10.1111/j.1552-6909.2007.00212.x Young, K., & Kruske, S. (2012). How valid are the common concerns raised against water birth? A focused review of the literature. Women Birth, 26(2),105–109. doi:10.1016/j.wombi.2012.10.006.
Nursing for Women’s Health
531
In Practice
Box 4.
Our Facility’s Hydrotherapy Procedures Procedure for Tub Filling 1. Place tub so it does not obstruct the bed from going through the doorway. 2. Place plastic floor cover protector on the floor and cover it with a bath blanket. 3. Place the empty tub on top of the protective floor covering. 4. Place the tub liner in the tub. 5. If the faucet has an aerator, remove the aerator. Attach the adapter to the faucet. 6. Attach the hose to the faucet adapter and tighten with wrench to prevent water spray. 7. Using the large clip, clip the hose on the inside of the tub to the tub liner or hand hold the hose. 8. Mixing hot and cold water, fill the tub to the fill line (dark red line) on the inside of the tub. It takes 8 to 10 minutes to fill the tub with 50 gallons of water. When a woman sits in the tub, her abdomen will be covered. More water can be added if needed. Do not leave the tub unattended while filling. 9. Check the water temperature. It should be >35°C/95°F and no higher than 37.8°C/100°F. 10. After filling the tub, remove the clip from the hose and return the clip to the tub toolbox. 11. After filling the tub, place the hose cap on the end of the hose to prevent water leakage. Using the wrench, remove the hose from the faucet and drain the hose in the sink, shower or toilet. 12. Remove the adapter from the faucet and put it back in the tub toolbox. 13. If a woman is not going to enter the tub immediately after it is filled, cover the tub with a portion of the tub liner and place a bath blanket or bed blanket over the liner to maintain the water temperature.
Procedure for Tub Draining With Wayne Utility Transfer Pump 1. Remove any debris from the water with debris net and discard. Debris will block the utility pump, and it will not drain the tub. 2. Place the utility transfer pump on a disposable towel or pad. Add 15 to 30 cc of vegetable oil to both the inlet and outlet to prime the pump. Attach the 6 yellow suction hose (supplied with the pump) to the inlet of the pump. Attach the garden hose to the outlet of the pump. (If the connections are not airtight, the pump will not prime.) 3. Place the end of the yellow hose in the tub and clip to the tub liner with the large clip. 4. Place the end of the garden hose in the toilet above the water line. Be sure to securely tape the hose to the toilet with duct tape. 5. Plug in the utility transfer pump into a ground fault outlet. If there are any water leaks, unplug the pump and use the wrench to tighten the hose connections. 6. It will take approximately 15 to 20 minutes to drain the tub. Never leave the pump unattended. 7. When the water level is low, lift the tub liner to direct water to the end of the tub. The pump will almost completely drain the tub. Unplug the utility transfer pump. Use a towel to remove any excess water that remains in the liner. 8. Cap the hose. 9. Remove and discard the liner in a biohazard container. 10. If the pump shuts off before the tub is drained, unplug the pump and wait at least 10 minutes. The pump will cool and automatically reset.
14. The tub supplies are in the tub toolbox and include thermometer, faucet adapter, wrench and duct tape. These should be returned to the tub toolbox.
532
Nursing for Women’s Health
Volume 19
Issue 6
Strategies for Providing Low-Cost Water Immersion Therapy With Limited Resources BRENDA BRICKHOUSE CHRISTINE ISAACS MEGHANN BATTEN AMBER PRICE Hydrotherapy During Labor Pain in labor varies greatly among women and can be influenced by physiologic, psychological and social factors (Jones et al., 2012). Water immersion therapy as a nonpharmacologic
Abstract At our university-affiliated medical center, a major renovation of the women’s health and birthing unit resulted in the temporary loss of the permanent tub used for water immersion therapy during labor. Because 40 percent of the women in the nurse-midwifery practice utilize hydrotherapy, we undertook a rigorous search for an interim solution. We developed a safe and cost-effective strategy that can be easily replicated and utilized by others to provide hydrotherapy for laboring women. DOI: 10.1111/1751-486X.12247 Keywords hydrotherapy | labor and birth | pain management in labor | water immersion
526
© 2015, AWHONN
http://nwh.awhonn.org
Photo courtesy of the author
T
The terms “hydrotherapy” and “water immersion” are often used interchangeably. Hydrotherapy can include the use of water in various modalities (e.g., heat packs, cold packs, steam, showers or bathing) for its psychological and physiologic therapeutic effects. For the purposes of this article, hydrotherapy is defined as water immersion with submersion in water deep enough to completely cover a pregnant woman’s abdomen (Cluett & Burns, 2009) during the active phase of labor.
Review of the Evidence A Cochrane review of 12 randomized trials (including 3,243 women) found no evidence of increased adverse maternal, fetal or neonatal effects from laboring in water (Cluett & Burns, 2009). The review noted a significant reduction in epidural, spinal and paracervical analgesia/ anesthesia rates of those women who utilized water immersion during labor as compared to controls (Cluett & Burns, 2009). The authors of one study noted that the first stage of labor was reduced by 32.4 minutes (Cluett, Nikodem, McCandlish, & Burns, 2004). There were no significant differences in assisted vaginal births, cesarean birth rates, use of oxytocin augmentation, perineal trauma or maternal infection (Cluett & Burns, 2009; Young & Kruske, 2012). There were no significant differences in Apgar scores < 7 at 5 minutes (Cluett & Burns, 2009; Dahlen, Dowling, Tracy, Schmied, & Tracy, 2012),
neonatal unit admissions or neonatal infection rates (Cluett & Burns, 2009). Women laboring in water had more freedom of movement (Maude & Foureur, 2007; Stark et al., 2008) and increased uterine contractions (Stark et al., 2008) while reporting decreased pain (DaSilva, DeOliveira, & Nobre, 2009) and increased satisfaction with their birth experience (Cluett & Burns, 2009). In women diagnosed with labor dystocia, water immersion decreased
Immersion into water increases buoyancy, increasing support to the extremities and providing a sense of weightlessness the need for labor augmentation with amniotomy and oxytocin (Cluett, Pickering, Getliffe, & Saunders, 2004). Water immersion was also associated with increased spontaneous vaginal births among nulliparous women (Burns, Boulton, Cluett, Cornelius, & Smith, 2012). Women described water immersion as creating an environment that promoted privacy, relaxation, freedom of movement and the ability to cope with pain (Maude & Foureur, 2007).
Steps to Initiate Water Immersion The certified nurse-midwives (CNMs) at our university medical center use water immersion routinely for labor management, and prior to October 2012 had the availability of a permanent immersion tub. Because 40 percent of the women in the midwifery practice utilized water immersion during labor, months prior to an anticipated renovation of the women’s health and
Box 1.
Hydrotherapy Kit: Supplies and Cost to Individual Item
Cost
½" × 25' hose (lead-free)
$15
Two-pack polymer hose cap
$1
Eco generic pool liner
$30 (ordered online)
Total
$46
December 2015 | January 2016
In Practice
modality for pain management has been utilized for centuries and can be used to safely manage pain in labor (Cluett & Burns, 2009; Garland & Jones, 2000). Immersion into water increases buoyancy, increasing support to the extremities and providing a sense of weightlessness (Stark, Rudell, & Haus, 2008), and decreases anxiety secondary to neuroendocrine response modification of psychophysiological processes (Benefield et al., 2010). Physiologically, the hydrostatic pressure from water immersion moves fluid from the extravascular space into the intravascular space with the potential to reduce blood pressure and edema (Florence & Palmer, 2003). Water immersion may increase uterine perfusion via decreased pressure on the vena cava and improved diuresis due to increased blood flow to the kidneys (Cluett & Burns, 2009).
Brenda Brickhouse, MS, CNM, WHNP-BC, is now retired and was previously a certified nurse-midwife and assistant clinical professor at VCU Medical Center in Richmond, VA. Christine Isaacs, MD, is an associate professor, director of the General Obstetrics & Gynecology Division and medical director of midwifery services at VCU Medical Center in Richmond, VA. Meghann Batten, MS, CNM, is a certified nurse-midwife and assistant clinical professor at VCU Medical Center in Richmond, VA. Amber Price, MSN, CNM, is vice president of the Women & Children’s Service Line at Henrioc Doctors’ Hospital in Richmond, VA. The authors report no conflicts of interest or relevant financial relationships. Address correspondence to: [email protected].
Nursing for Women’s Health
527
birthing unit (which would involve a temporary loss of the permanent tub), the CNMs began developing a strategy to provide uninterrupted access to water immersion for the women in their midwifery practice. Initially, the strategy was to implement the use of one portable tub, but during the renovation, the number of women requesting water immersion increased, so an additional portable tub was added.
Multidisciplinary Commitment
Logistics We had to find a portable immersion tub that the smaller labor rooms
528
Nursing for Women’s Health
Women described water immersion as creating an environment that promoted privacy, relaxation, freedom of movement and the ability to cope with pain (15' × 10.5') would accommodate and that would be suitable for laboring women. The round birthing pools were too large for a small labor room and were logistically impractical. For trial purposes and to test feasibility, we used and later purchased a 100 gallon (378.5 L) stock tank. Without changing the configuration of the labor room and with the removal of a spare chair and bedside table, the “tub” (52" long × 32" wide × 24" deep) fit easily in the smallest labor room. The tub is placed so that door access for moving the bed is not blocked and the site where the infant warmer is placed is uncompromised. Although the tub is compact, it has comfortably accommodated women weighing in excess of 299 lbs and with heights up to 6', while allowing
abdominal submersion and the ability to labor in different positions (see Figures 1 and 2).
Equipment The sink faucets in the labor rooms presented a challenge. Members of the engineering staff removed the aerators from the faucets so that an adapter could be attached to connect the hose to the faucet for filling the tub. With their assistance, we found proper fitting male and female adapters. Two sets of adapters are kept in the tub toolbox, as are a thermometer, wrench, two large clips and duct tape (see Box 2). If necessary, duct tape can be used to attach the hose to the sink faucet. The greatest equipment challenge was finding the correct drainage
Volume 19
Issue 6
Photo courtesy of the author
The first step in the process was a multidisciplinary commitment involving nurses, nurse managers, obstetricians, maternal-fetal medicine physicians, infection control staff (Department of Epidemiology) and members of Plant Operations and Planning (Engineering). Because this was a temporary solution to achieve water immersion, the CNMs assumed the responsibility for filling, draining, cleaning, storing, purchasing and restocking tub supplies. The women’s birthing unit provided reimbursement for expenditures. Also, prior to implementing the official use of the portable tub system, three “tub trials” were completed to ensure real-time feasibility. The system involves individual women making a commitment to supply their own “hydrotherapy kit” for use in labor. Each woman receives a brochure titled Hydrotherapy During Renovations that explains the renovation circumstances, the temporary loss of the permanent tub and the availability of a portable tub. The brochure contains information for creating their personal kit, which includes a list of needed supplies, purchasing information and cost (see Box 1). Women are advised that the supplies are essential for filling and draining the tub, as well as for infection control.
In Practice
Figure 1.
Tub With Liner
Figure 2.
Tub With Pump for Drainage
Photos courtesy of the author.
pump. A utility transfer pump that sits outside the tub, rather than a submersible pump that is placed directly into the tub for draining, was purchased. The utility transfer pump produces more noise than the submersible pump and takes 15 to 20 minutes to drain the tub, but
December 2015 | January 2016
proved to be the most efficient option for water removal.
Guidelines and Procedures Suggested guidelines for water immersion are shown in Box 3 and our medical center’s water
Nursing for Women’s Health
529
immersion procedures are shown in Box 4.
Cleaning and Infection Control In conjunction with our Department of Epidemiology and utilizing the Centers for Disease Control and Prevention’s (CDC) Guidelines for Environmental Infection Control in Health Care Facilities-Hydrotherapy Tanks and Pools (CDC, 2012), we developed cleaning procedures including the type of disinfectant, methods used to clean the tub and related equipment. The tub used in this facility is made of high-density polyethylene, and the manufacturer provides general chemical resistance characteristics of this product online. Per the CDC guidelines, the tub is wiped down inside and out with an Environmental Protection Agency (EPA) registered product as set by our institution facility policy. To clean the utility transfer pump and yellow suction hose, a 10:1 solution of water and sodium hypochlorite is pumped through both. The outside of the pump, the hose attachment fittings on the pump and the yellow suction hose are wiped with an EPA-registered product as set by our institution facility policy. All equipment is cleaned prior to removal from the labor and birthing room.
Box 2.
Hydrotherapy Equipment and Supplies: Cost to Facility 100-Gallon stock tank (high-density polyethylene)
$75
120-Volt transfer utility pump
$82
Canola oil for priming pump
$3
Bleach for cleaning pump (three cases)
$27
8" × 100" Roll clear plastic (for floor covers)
$36
½" × 25' Hose
$15
10 Aqua nets 5" × 16" (less than debris nets)
$26
Craft toolbox
$10
Clip set*
$8
10" Wrench*
$11
Roll of duct tape*
$6
Female aerator adapter × 2*
$12
Male aerator adapter × 2 (furnished by Plant Operations and Planning)* Thermometer (furnished by Plant Operations and Planning)* Nonsterile shoulder length gloves (furnished by birthing unit) Moving dolly (furnished by birthing unit) Total *Items stored in the toolbox.
2009). It is for these reasons that when faced with limitations during a renovation of the women’s health and birthing unit, we had to search for a
The steps developed and detailed here have proven to be an effective, low-cost, practical way to bring water immersion therapy to places with limited resources
Conclusion Research supports that water immersion during labor is an effective nonpharmacologic intervention that promotes relaxation (Benfield et al., 2010), reduces pain and anxiety, increases maternal satisfaction with the childbirth experience and has no increase in adverse maternal, fetal or neonatal outcomes (Cluett & Burns,
530
Nursing for Women’s Health
$301
practical, low-cost solution to maintain water immersion therapy for laboring women. The steps developed and detailed here have proven to be an effective, low-cost, practical way to bring water immersion therapy to places with limited resources (whether due to space, finances or lack of existing infrastructure). These steps can be easily duplicated so that laboring
women have access to safe water immersion options. NWH
Acknowledgments The authors thank VCU Medical Center’s Labor & Delivery staff, as well as members of the Department of Plant Operations & Planning and of the Department of Epidemiology for their assistance in making these efforts successful.
References Benfield, R. D., Hortobagyi, T., Tanner, C. J., Swanson, M., Heitkemper, M. M., & Newton, E. R. (2010). The effects of hydrotherapy on anxiety, pain, neuroendocrine responses, and contraction dynamics during labor. Biological Research for Nursing, 12(1), 28–36. doi:10.1177/1099800410361535 Burns, E. E., Boulton, M. G., Cluett, E., Cornelius, V. R., & Smith, L. A. (2012). Characteristics, interventions, and
Volume 19
Issue 6
In Practice
Box 3.
Suggested Guidelines for Water Immersion PRIOR TO WOMAN ENTERING TUB Normal maternal and fetal surveillance Singleton gestation Cephalic presentation Gestational age ≥ 37 weeks Category 1 tracing The woman has committed to and provides her hydrotherapy supplies as detailed previously
WHILE WOMAN IS IN TUB Maternal and fetal surveillance according to facility policy Intermittent fetal monitoring according to facility policy Continuous electronic fetal monitoring (CEFM) via telemetry for oxytocin induction/augmentation of labor CEFM via telemetry for trial of labor after cesarean
outcomes of women who used a birthing pool: A prospective observational study. Birth, 39(3), 192–202 Centers for Disease Control and Prevention (CDC). (2012). Guidelines for environmental infection control in health care facilities—Hydrotherapy tanks and pools. Atlanta: Author. Retrieved from www.cdc.gov/healthywater/ swimming/pools/hydrotherapy-tank-pooloperation.html Cluett, E. R., & Burns, E. E. (2009). Immersion in water in labour and birth (review). The Cochrane Database of Systematic Reviews, Apr 15(2),CD000111. doi: 10.1002/14651858. CD000111.pub3. Cluett, E. R., Nikodem, V. C., McCandlish, R. E., & Burns, E. E. (2004). Immersion in water in pregnancy, labour and birth. Cochrane Database Systematic Reviews. doi:10. 1002/14651858 Cluett, E. R., Pickering, R. M., Getliffe, K., & Saunders, N. J. (2004). Randomized controlled trial of laboring in water compared with standard of augmentation for management of dystocia in first stage of labour. British Medical Journal, 328, 314–318. doi:10.1136/bmj.37963.606412 Dahlen, H. G., Dowling, H., Tracy, M., Schmied, V., & Tracy S. (2012). Maternal and perinatal outcomes amongst low risk women giving birth in water compared to six birth positions on land. A descriptive cross sectional study in a birth centre over 12 years. Midwifery, 29(7), 759–764. doi:10.1016/j.midw.2012.07.002
December 2015 | January 2016
DaSilva, F. M. B., DeOliveira, S. M. J. V., & Nobre, M. R. C. (2009). A randomized controlled trial evaluating the effect of immersion bath on labour pain. Midwifery, 25(3), 286–294. doi:10.1016/j.midw.2007.04.006 Florence, D. J., & Palmer, D. G. (2003). Therapeutic choices for the discomforts of labor. Journal of Perinatal & Neonatal Nursing, 17, 238–249. Garland, D., & Jones, K. (2000). Waterbirth: Supporting practice with clinical audit. MIDIRS Midwifery Digest, 10(3), 333–336. Jones, L., Othman, M., Doswell, T., Alfirevic, Z., Gates, S., Newburn, M., … Neilson, J. P. (2012). Pain management for women in labor: An overview of systematic reviews. The Cochrane Database of Systematic Reviews, Mar 14(3), CD009234. doi: 10.1002/14651858.CD009234. pub2. Maude, R. M., & Foureur, M. J. (2007). It’s beyond water: Stories of women’s experiences of using water for labour and birth. Women and Birth, 20(1), 17–24. doi:10.1016/j.wombi.2006.10.005 Stark, M. A., Rudell, B., & Haus, G. (2008). Observing position and movement in hydrotherapy: A pilot study. Journal of Obstetric, Gynecologic and Neonatal Nursing, 37(1), 116–122. doi:10.1111/j.1552-6909.2007.00212.x Young, K., & Kruske, S. (2012). How valid are the common concerns raised against water birth? A focused review of the literature. Women Birth, 26(2),105–109. doi:10.1016/j.wombi.2012.10.006.
Nursing for Women’s Health
531
In Practice
Box 4.
Our Facility’s Hydrotherapy Procedures Procedure for Tub Filling 1. Place tub so it does not obstruct the bed from going through the doorway. 2. Place plastic floor cover protector on the floor and cover it with a bath blanket. 3. Place the empty tub on top of the protective floor covering. 4. Place the tub liner in the tub. 5. If the faucet has an aerator, remove the aerator. Attach the adapter to the faucet. 6. Attach the hose to the faucet adapter and tighten with wrench to prevent water spray. 7. Using the large clip, clip the hose on the inside of the tub to the tub liner or hand hold the hose. 8. Mixing hot and cold water, fill the tub to the fill line (dark red line) on the inside of the tub. It takes 8 to 10 minutes to fill the tub with 50 gallons of water. When a woman sits in the tub, her abdomen will be covered. More water can be added if needed. Do not leave the tub unattended while filling. 9. Check the water temperature. It should be >35°C/95°F and no higher than 37.8°C/100°F. 10. After filling the tub, remove the clip from the hose and return the clip to the tub toolbox. 11. After filling the tub, place the hose cap on the end of the hose to prevent water leakage. Using the wrench, remove the hose from the faucet and drain the hose in the sink, shower or toilet. 12. Remove the adapter from the faucet and put it back in the tub toolbox. 13. If a woman is not going to enter the tub immediately after it is filled, cover the tub with a portion of the tub liner and place a bath blanket or bed blanket over the liner to maintain the water temperature.
Procedure for Tub Draining With Wayne Utility Transfer Pump 1. Remove any debris from the water with debris net and discard. Debris will block the utility pump, and it will not drain the tub. 2. Place the utility transfer pump on a disposable towel or pad. Add 15 to 30 cc of vegetable oil to both the inlet and outlet to prime the pump. Attach the 6 yellow suction hose (supplied with the pump) to the inlet of the pump. Attach the garden hose to the outlet of the pump. (If the connections are not airtight, the pump will not prime.) 3. Place the end of the yellow hose in the tub and clip to the tub liner with the large clip. 4. Place the end of the garden hose in the toilet above the water line. Be sure to securely tape the hose to the toilet with duct tape. 5. Plug in the utility transfer pump into a ground fault outlet. If there are any water leaks, unplug the pump and use the wrench to tighten the hose connections. 6. It will take approximately 15 to 20 minutes to drain the tub. Never leave the pump unattended. 7. When the water level is low, lift the tub liner to direct water to the end of the tub. The pump will almost completely drain the tub. Unplug the utility transfer pump. Use a towel to remove any excess water that remains in the liner. 8. Cap the hose. 9. Remove and discard the liner in a biohazard container. 10. If the pump shuts off before the tub is drained, unplug the pump and wait at least 10 minutes. The pump will cool and automatically reset.
14. The tub supplies are in the tub toolbox and include thermometer, faucet adapter, wrench and duct tape. These should be returned to the tub toolbox.
532
Nursing for Women’s Health
Volume 19
Issue 6