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 womens 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

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http://nwh.awhonn.org

Photo courtesy of the author

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 womans
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 womens health and

Box 1.

Hydrotherapy Kit: Supplies and Cost to Individual

Item

Cost

" 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 &
Childrens Service Line at
Henrioc Doctors Hospital
in Richmond, VA. The
authors report no conflicts
of interest or relevant
financial relationships.
Address correspondence to:
thbrickhouse@aol.com.

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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

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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

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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 womens 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 centers water

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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 Preventions (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

" 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 womens 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,

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$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 Centers
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), 2836.
doi:10.1177/1099800410361535
Burns, E. E., Boulton, M. G., Cluett, E.,
Cornelius, V. R., & Smith, L. A. (2012).
Characteristics, interventions, and

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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),
192202
Centers for Disease Control and Prevention
(CDC). (2012). Guidelines for environmental
infection control in health care facilitiesHydrotherapy 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,
314318. 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), 759764.
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), 286294.
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, 238249.
Garland, D., & Jones, K. (2000). Waterbirth:
Supporting practice with clinical audit. MIDIRS
Midwifery Digest, 10(3), 333336.
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). Its beyond
water: Stories of womens experiences of using
water for labour and birth. Women and Birth,
20(1), 1724. 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), 116122.
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),105109. doi:10.1016/j.wombi.2012.10.006.

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In Practice

Box 4.

Our Facilitys 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 >35C/95F and no higher than
37.8C/100F.
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.

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