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What we learned about Waterbirth from a case of Legionella

In January 2014, a baby who was born in the water, contracted Legionnaire’s disease and died approximately 3 weeks after her birth. The birth took place at home, using the client’s well water and a birth tub given to her by her midwife. The water was treated with enzymes and sat heated and filled in the family’s home for two weeks. The case was reported to the Texas Department of State Health Services and was quickly picked up by many news outlets. Overnight, many news sources were reporting this tragic death. The Center for Disease Control (CDC) reported that, “The death highlighted the need for infection control education, client awareness and standardization of cleaning procedures in Texas midwife facilities.” The case was heard by the Texas Midwifery Board. Because the pool had been cleaned and there was no legionella found in either the well water or the pool, the case was dismissed. However, it inspired the board to create a committee dedicated to writing guidelines for water immersion during labor and delivery that addressed exactly what the CDC was calling for - infection control education, client awareness and standardization of cleaning procedures. Many of us realized that although we never had any bad outcomes, we were sorely lacking in information and knowledge as to adequate infection control and cleaning procedures. Many of us assumed that if we were using a liner with the portable pools, all was well. Likewise, we learned that many centers were using jetted or heated pools - two styles of pools that actually harbor biofilms, which is the perfect growth medium for legionella and other waterborne bacteria. As we began our research, we discovered that there are no formal published guidelines on water birth in this country. We had to turn to guidelines from the Royal College of Midwives and well researched articles from Rebecca Dekker and Journal of Midwifery and Women’s Health. We were excited to be on the leading edge of advancing the safety of midwifery and waterbirth through the creation of these guidelines. What is Legionella? Legionella is a family of bacteria that lives inside of an amoeba. It is very difficult to detect since you can not test the water directly for it. In certain ideal conditions, this amoeba with legionella grows easily. These conditions just happen to be the ideal conditions for a water birth - warm untreated water, possibly containing blood and/or feces, that has been sitting for a long time. A person can become infected with Legionella simply by breathing in the steam or by aspiration from contaminated water. Hospitals with closed water systems, are particularly susceptible to legionella outbreaks. A person infected with legionella has a wide range of symptoms - cough, low-grade fever, nausea, vomiting and it quickly progresses to pneumonia and multi-organ failure. People with low functioning immune systems - including babies - are especially vulnerable to legionella. Initially, we tried to ascertain the numbers of babies who had died as a result of contracting Legionnaire’s disease. We could only find 4 reported cases in the last 5 years - worldwide! Of course we wondered what was the big deal? This is an extremely rare issue. However, through many conversations with experts and the mother of the deceased baby (who coincidentally became an invaluable asset to our committee) we surmised that perhaps many more babies have died from Legionnaire’s disease, it just doesn’t occur to doctors to test for it. “Clinical awareness is critical for rapid diagnosis and treatment of Legionnaires’ disease. Due to nonspecific clinical presentation, it is not possible to predict the presence of Legionella infection and under diagnosis of Legionnaires’ disease is common.” Guidelines for Water Immersion and Waterbirth As midwives, we are the experts in normal birth. We are also the experts in waterbirth. So we turned to not only the research, but our own experience and knowledge. We reminded each other of the benefits of water immersion during labor. We can see the relief a mother experiences as she enters the pool. We can see the beautiful unfolding of the baby who is allowed to remain peacefully in the water. We know that the mother’s perineum is well protected by the warmth and gentle support of the water. Relying on poor evidence, ACOG continues to ask if water birth is safe and cautions that waterbirth is an “experimental practice.” Midwives know of its value and safety. In a midwife’s practice, water birth is far beyond an experiment. When a woman is submerged up to her breasts, her body releases a flood of good, labor enhancing hormones. These hormones are effective in the body for about 90 minutes. After this time, it is best for the mom if she exists the pool for approximately 30 minutes. At which time, once she immerses in the water again, she receives the benefits of the flood of hormones again. This is an incredible benefit to the laboring mother. There are times when waterbirth is not the best birth option. For example, we know that if a baby is exhibiting fluctuations in the heart rate, indicating possible distress, the dive reflex that prohibits the baby from taking a breath while submerged in water is temporarily turned off. In this case, it is best of the baby is born “on land.” Likewise, there are some emergency procedures that are often managed more effectively or easily when the midwife has full access to the mom and the baby. Additionally, cord avulsion (when the cord tears from the placenta) occurs more frequently in waterbirths. In the guidelines, we tried to account for the many scenarios birth has to offer, while at the same time allowing space for the midwife’s experience, knowledge and intuition to determine the course of care. The guidelines also offer a list of talking points for the midwife and the client. We decided it was important for the midwife/client team to discuss the benefits, risks and alternatives to water immersion. We also decided it was important for there to be agreement between the midwife and the client that if the midwife says to stand or leave the pool, the client will do her best to comply. The midwife’s discretion is an important component to the safety of birth, regardless of the style and setting. Often midwives are concerned about being able to accurately assess blood loss during the 3rd stage. When accurate assessment is not possible, the midwife can also take into account the client’s emotional and physical response. Is she alert? Interacting with her baby? Curious about the baby? How are her vitals? If the midwife has any question, the client can be removed from the pool. Finally, one of the more challenging aspects of waterbirth is the performance of Neonatal Resuscitation. The guidelines offer some suggestions of how to handle this situation. It can be challenging to keep the baby’s airway open while the mom is in the pool, so the midwife must pay particular attention to this. The ventilations must be effective in order for them to work. It helps to have a firm surface such as a CPR board with a heating pad and towels near by. Drying the baby’s face ensures a better seal whether you are doing mouth to mouth or using a bag and mask. We hope that these guidelines are both intuitive and evidence based. As midwives, we often find ourselves seeking the middle path between the art and the science. Pool Setup and Cleaning Recommendations In the third part of the recommendations, we focussed on standardizing cleaning procedures. Two of the main questions that arose, as a direct result of the legionella case in Texas, was is the pool part of the midwife’s equipment? If so, should it always remain in the midwife’s possession? In this case, the pool was left - filled - at the client’s home for approximately 2 weeks. Although we never answered that question directly since there was a variety of opinions, we did categorize the pool as a semi-critical item. A semi-critical item is any medical item that comes into contact with mucous membranes or non-intact skin. Deciding whether an item is a non-critical item (such as a stethoscope), a semi-critical item (such as a doppler or pool) or a critical item (such as suturing equipment and syringes) determines how the item is to be cleaned, sanitized and/or sterilized. The other big recommendation that came out of our research and discussions was the issue of jetted pools or pools with recirculating water systems. Because it is nearly impossible to fully clean the biofilm out of all of the tubing in the heaters, jets and overflow drains, these types of pools are no longer recommended for waterbirth. If you use these pools, it is recommended that you use a liner to cover the areas of potential bacterial growth. Finally, we gave a list of cleaning agents. Any cleaning agent that kills tuberculosis should kill all of the concerning organisms. Many midwives will be happy to know that products such as Simple Green D-Pro 5 and Seventh Generation Wipes are tuberculocides and recommended by the Environmental Protection Agency. One of the challenges we faced was creating recommendations for both birth centers as well as Licensed Midwives in a solo practice. The recommendations accommodate these different styles of practice and can be used by any midwife who is attending waterbirths. We are excited to have had the opportunity to put these guidelines together. We are excited to offer them to the midwives of Texas. We are especially excited to be on the leading edge of safe midwifery practices. As far as we know, we are the only governing body to offer such guidelines. We hope our experience can be a learning opportunity for all. We have all learned so much in the process and I have no doubt we are better, more conscientious midwives because of it. But most of all, I want to say and huge thank you to the mother of the baby who died. Her death has not been in vane.

This article was published in Midwifery Today

Guidelines for Water Immersion in Labor and Delivery can be found…..

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