Author: K.D.Brainin

Abstract: 

In light of current societal and professional concerns regarding the medicalisation of childbirth and an apparent clinical culture of anxiety and fear of litigation, emerging evidence emphasises the importance of promoting normality within clinical practice, and the need for individualised, client-centred choice and control. 

This article examines the use of water immersion as a facilitator of normal labour and birth. In defining the concept of normality, the article discusses the advantages of water immersion in decreasing maternal pain and use of other analgesics, critically increasing maternal control and satisfaction, and limiting medicalised intervention need. 

Furthermore, supporting the physiological advantages of relaxation and maternal movement linked to the use of water in labour,water immersion promotes improved fetal position and enhanced labour progress. 

Importantly however, the article further identifies current hindering factors to facilitating water immersion implementation, critically the current lack of sound methodological evidence and research rigor regarding potential adverse neonatal outcomes.

It concludes, despite obvious promotion of normality in childbirth, that further robust qualitative and quantitative research is needed to clarify the overall appropriateness of this practice. This would help practitioners to decide if this method is safe and be more informed of the risks and benefits before recommending it to women.

Introduction

The drive towards promoting normality in labour is evident in current research and policy drivers (RCM 2013; Downe 2008). However, when reading the literature around normal birth, it is apparent that no single set of criteriarepresents an accepted definition of ‘normal labour’ (National Institute of Clinical Excellence [NICE] 2007; Royal College of Midwives [RCM] 2013). 

This debate around what constitutes normality in labour has dominated research and care provision for decades, but, for the purpose of this review, the Midwifery Care Working Party (MCWP) definition will be utilised as the referent. 

This definition states that ‘normal labour’ is spontaneous in onset and progression, without the use of spinal, epidural or general anaesthesia, or medicalised intervention (MCWP 2007).Of particular interest in the support of normality in labour is the issue of medicalised intervention.

For instance, environmental pressures, such as how care is co-ordinated and led,can hinder the process (Russell 2011) and has inadvertently shifted the focus away from normality. Empowering women to take the lead in their own birthing experience, gain personal control and as a result manage their pain more effectively, underpins the definition of normality, whilst also overcoming and eliminating the need for medicalisation (Royal College of Obstetricians and Gynaecologists/Royal College of Midwives (RCOG/RCM 2006). 

Adequate pain relief, such as epidural and pethidine (Nystedt, Edvardsson & Willman 2004; Cho, Lee & Ernst 2010), may induce a more positive birthing experience and personal control; however such methods do not promote normality. For this reason, practices such as water immersion as a non-medicalised method of personal control, may advantageously promote such concepts. 

This review aims to present an overview of current literature around the benefits and disadvantages of using such a method to manage labour pain with an emphasis on critiquing methodological strengths and weakness.

Water immersion and pain relief

Much of the research into pain relief facilitation in childbirth concentrates on comparing the outcomes of water immersion with no intervention during the first stage of labour, in the form of unblinded randomised controlled trials (RCT) (Benfield et al. 2001; Cluett, Pickering, Getliffe & Saunders 2004; Eckert, Turnbull & MacLennan 2001; Ohlsson et al. 2001). 

Despite the limitation of unblinded methodology in these studies, due to the nature of the intervention, collectively they conclude that water immersion has beneficial pain relief implications in comparison with no intervention, and a positive impact on maternal control and normality.

Barbosa da Silva, Vasconcellos de Oliveira and Nobre (2009), in comparing pain relief magnitude in first stage bathing and non-bathing women, conclude that pain is less apparent, and pain progresses lower in bathing cohorts, but overall pain relief satisfaction is highly significant (Pagano et al. 2010; RCOG/RCM 2006). 

However, as this study only involved nulliparous women (first time pregnant)these findings only offer limited insights intothe women’s evaluation of labour pain. The study acknowledges the implications of using such a restricted sample group in representing the entire birthing population.

Regardless of these limitations, the reported reduction in intensity of pain and use of additional analgesia, as concluded within the study’s findings, is indicative of the potential for water immersion to contribute to the promotion of normality in labour by reducing medicalisation. 

This has been replicated by other studies where a decrease in opioid use (Mollamahmutoglu et al. 2012; Cluett, Nikodem, McCandlish & Burns 2009) and incidence of epidural and spinal anaesthetics (Cluett & Burns 2009; Burns et al. 2012) has been concluded. 

Women’s perception of water immersion efficacymay differ prior to commencement of this activity, therefore, this could influence their perception of pain relief (Cluett, Nikodem, McCandlish & Burns 2009); further research is needed to explore this hypothesis.

One qualitative study by Maude and Foureur (2007), which involved interviews with five women who experienced water birth at different post-natal periods, suggests that the anticipation of getting into water and consequential relaxation accelerates the rate of cervical dilation. 

Due to induced cardiovascular changes, any elevation in anxiety hormones is decreased by a reduction in blood pressure, further facilitated by an increased level of endorphins (Benfield 2002; Cluett et al. 2009). Relaxation and a sense of personal control as a response to this, is arguably the main basis for pain relief in water immersion. 

Literature evidence agrees that pain is not eliminated by water; however, relaxation provides a release from the pain experience, and a sense of comfort and satisfaction (McNeil & Jomeen 2010). A larger range of maternal movement improves normal labour progression and there are reported improvements in fetal position and flexion (Cluett et al. 2009; Burns 2004). 

However, the methodology of Maude and Foureur’s (2007) study, in conducting differently timed postpartum interviews, raises questions of recall bias, and potential changing of emotions and opinions over time.

A reduction in medicalised intervention

One point, highly illustrated within the literature, includes the impact of water immersion on the reduced need for medicalised intervention such as episiotomy and induction (Burns et al. 2012; Geissbuehler, Stein & Eberhard 2004). Mollamahmutoglu et al. (2012) report that water immersion results in a shorter second stage of labour,with the need for induction of labour being significantly decreased. 

In connection to facilitating normality through a more natural birthing process, large observational retrospective studies, such as Burns et al. (2012), conclude thata reduced need for medicalised interventions is also more prevalent in midwifery-led home water births. Care within the home is arguably another factor in facilitating normality for the birthing woman. However, a lack of a control group for this particular study, limits the reliability of this study’s conclusions.

Second and third stage management and physiological advantages

Despite water being recommended by national guidance (NICE 2007), there appears to be a small amount of evidence available that concerns labouring in water in the first and second stages. Further water immersion research is needed around these stages of labour, especially in relation to risks associated with delivery of the third stage of labour in water.

However, research undertaken with women who have had a water birth, shows a reduction in maternal adverse outcomes and need for specialised care, compared with vaginal delivery controls. A reduced incidence of perineum tears (Burns et al. 2012), maternal infections (Benfield et al. 2001) and postpartum haemorrhage (Mollamahmutoglu et al. 2012; Benfield 2002), are some of the reported outcomes,all of which promote normality and could, in addition, improve the pain experience.

Definition discrepancies

In analysis of the evidence, various definitions for water immersion can be identified, indicating a lack of homogeneity in research literature. Differences in the size of baths/pools, the depth of water and length of time exposed to the intervention, all contribute significantly to the degree of exposure experienced; however, little attention to date has been paid to these factors. Benfield et al. (2001) conducted a RCT study which exposed its participants to water for exactly an hour.

This, therefore, increased the consistency of their exposure findings; however,the authors state that the pool was shallow in comparison to those generally used on labour wards, thereby limiting the reliability and appropriateness of their findings to practice. Other studies also highlight similar weaknesses. Eckert et al. (2001) used a larger pool during its intervention; however, exposure time varied according to the woman’s preference. 

Significantly, this study also allowed its control group the option of a shower, thereby introducing bias and limiting the reliability of the findings, as exposure to a shower may also have similar pain relief properties as water immersion (Stark & Miller 2009).

Barriers to practice implementation

Interestingly, one factor apparent within the evidence is the lack of investigation into the effects of temperature control, including inconsistencies in temperatures usage and the effect on any potential outcomes. NICE (2007) recommends a water temperature no higher than 37.5c, and advises this should be monitored hourly to ensure maternal comfort and apyrexia (absence of a fever).

Eckert et al. (2001) recognised the importance of temperature control in their RCT study; however,they concludedthat only 50 per cent of the 85 women in the intervention group had their temperatures recorded hourly. In comparison, Benfield et al (2001) assessed water temperature on strict fifteen minute intervals; however, the temperature was allowed to escalate as high as 38c. 

Taking these inconsistencies into account, analysis of the overall literature regarding temperature control and potential pain relief is difficult, and the ability to comment on this specific factor and its relevance in facilitating normal labour remains limited. Evidently, further research is needed in order to eliminate the discrepancies in the methodology, thereby allowing results to be more comparable.

Directly linked to the issue of temperature monitoring is the importance of fetal monitoring. Interestingly, only one study has been found that specifies how fetal heart monitoring was conducted during labour (Mollamatutoglu et al. 2012). On the other hand, a quantitative study conducted by Carpenter and Weston (2012), investigating the differences between respiratory distress in water and land birth neonates, concludes that, despite no significant difference in initial APGAR scores, water immersed neonates have more severe abnormal changes identified through x-ray. 

As this study involved a higher proportion of water birth inspected x-rays in comparison to land birth, this limits the rigor of the methodology, and the exclusion of co-morbidities, such as encephalopathy and congenital heart disease, indicates potential confounding factors. However, the study does conclusively identify the need of further research into potential adverse neonate outcomes after initial APGAR assessment. 

The lack ofstudies into this phenomenon is widely recognised in the literature; the only study to extend assessment over the immediate neonatal period was conducted by Cluett et al. (2004), and thisstudied babies only up to day ten postpartum. Higher incidence of resuscitation (Eckert et al. 2001) and near-drowning (Pinette, Wax & Wilson 2004) further question water immersion as a safe facilitator of normal birth; however, conclusive evidence regarding neonate outcomes is scarce to date; a reliable evidence-based recommendation for practice can only be made once further research has been conducted.

Potentially the largest barrier to water immersion provision so far, does not involve the actual use of water, but the attitudes of the professionals in general and midwives in particular towards its use. Lack of confidence, limited training and pressures from the ward environment seem, on occasions, to override the professional requirement for midwives to facilitate a woman’s choice (Russell 2011).

Working in a medical environment, which super-values intervention over the promotion of a natural birth, has also been identified as an important barrier (Russell 2011).Subsequently, it can be inferred that institutional factors are key in influencingtheuse of water immersion and its potential role in normality facilitation. 

However, the study by Russell (2011) only used a small sample size and findings cannot be readily generalised across the NHS or the entire midwifery profession. Other studies scoping current practice would help understand the use of water in labour in the UK.

Conclusion

As concluded by the current evidence base, research literature largely concurs that water immersion during the first stage of labour is a beneficial, natural method of pain relief. 

This is due to a decreased need for medicalised interventions and additional analgesia, and an increase in personal control and relaxation, consequently facilitating normality in childbirth. 

Lack of evidence on the latter stages of labour, the influence that temperature might have on the labour and/or the baby, and the implications of bathing tub dimensions, require that well conducted, methodologically strong and varied studies of all potential outcomes are carried out.

Despite numerous gaps in the evidence, one significant, largely inconclusive area remains: the lack of research into adverse neonatal outcomes and, specifically, any longer term detrimental effects. Achieving a better understanding of those, could prove advantageous in increasing the uptake of water immersion during labour as facilitator of normality in childbirth.

References

Barbosa da Silva, F.M., Vasconcellos de Oliveira, S.M.J. & Nobre, M.R.C. 2009. ‘A randomised controlled trial evaluating the effect of immersion bath on labour pain’, Midwifery 25, 286-294.

Benfield, R.D. 2002. ‘Hydrotherapy in labor’, Journal of Nursing Scholarship 34(4), 347-352.

Benfield, R.D., Herman, J., Katz, V.L., Wilson, S.P.& Davis, J.M. 2001. ‘Hydrotherapy in Labor’, Research in Nursing & Health 24, 57-67.

Burns, E.E., 2004. ‘Water: what are we afraid of?’, The Practising Midwife 7(10), 17-19.

Burns, E.E., Boulton, M.G., Cluett, E., Cornelius, V.R. & Smith, L.A. 2012. ‘Characteristics, interventions, and outcomes of women who used a birthing pool: a prospective observational study’, Birth 39(3), 192-202.

Carpenter, L. & Weston, P. 2011. ‘Neonatal consequences from water birth’, Journal of Paediatrics and Child Health 48, 419-423.

Cho, S.H., Lee, H. & Ernst, E. 2010. ‘Acupuncture for pain relief in labour: a systematic review and meta-analysis’, An International Journal of Obstetrics and Gynaecology 117, 907-920.

Cluett, E.R. & Burns, E.E. 2009. ‘Immersion in water in labour and birth’, Cochrane Database of Systematic Reviews 2, 1-56.

Cluett, E.R., Pickering, R.M., Getliffe, K, & Saunders, N.J.S.G. 2004. ‘Randomised controlled trial of labouring in water compared with standard of augmentation for management of dystocia in first stage of labour’, British Medical Journal 328(7435), 1-6.

Cluett, E.R., Nikodem, C.V.C., McCandlish, R.E. & Burns, E.E. 2009. ‘Immersion in water in pregnancy, labour and birth’, Cochrane Database of Systematic Reviews 1, 1-33.

Downe, S. 2008. Normal Childbirth, evidence and debate (2nd edition). Oxford: Churchill Livingstone.

Eckert, K., Turnbull, D. & MacLennan, A. 2001. ‘Immersion in water in the first stage of labour: a randomised controlled trial’, Birth 28(2), 84-93.

Geissbuehler, V., Stein, S. & Eberhard, J. 2004. ‘Waterbirths compared with landbirths: an observational study of nine years’ Journal of perinatal medicine 32(4), 308-314.

Maternity Care Working Party. 2007. ‘Making normal birth a reality-consensus statement from the Maternity Care Working Party-our shared views about the need to recognise, facilitate and audit normal birth’. London: Maternity Care Working Party.

Maude, R.M. & Foureur, M.J. 2006. ‘It’s beyond water: stories of women’s experiences of using water for labour and birth’, Women and Birth 20, 17-24.

McNeil, A. & Jomeen, J. 2010. ‘“Gezellig”: a concept for managing pain during labour and Childbirth’, British Journal of Midwifery 18(8), 515-520.

Mollamahmutoglu, L., Moraloglu, O., Ozyer, S., Su, F.A., Karayalcin, R., Hancerlioglu, N.,Uzunlar, O., & Dilmen, U. 2012. ‘The effects of immersion in water on labor, birth and newborn and comparison with epidural analgesia and conventional vaginal delivery’, Journal of Turkish German Gynecological Association 13, 45-49.

National Institute of Clinical Excellence (NICE). 2007. ‘Intrapartum care-care of healthy women and their babies during childbirth’. London: National Institute of Clinical Excellence.

Nystedt, A., Edvardsson, D., & Willman, A. 2004. ‘Epidural analgesia for pain relief in labour and childbirth- a review with a systematic approach’, Journal of Clinical Nursing 13, 455-466.

Ohlsson, G., Buchhave, P., Leandersson, U., Nordstrom, L., Rydhstrom, H. & Sjolin, I. 2001. ‘Warm tub bathing during labor: maternal and neonatal effects’, Acta Obstetricia et Gynecologica Scandinavica 80(4), 311-314.

Pagano, E., De Rota, B., Ferrando, A., Petrinco, M., Merletti, F., Gregori, D. 2010. ‘An economic evaluation of water birth: the cost-effectiveness of mother well-being’, Journal of Evaluation in Clinical Practice 16, 916-919.

Pinette, M.G., Wax, J. & Wilson, E. 2004. ‘The risks of underwater birth’, American Journal of Obstetrics and Gynecology 190, 1211-1215.

Royal College of Midwives (RCM). 2013. ‘Campaign for Normal Birth’. Available online at: http://www.rcmnormalbirth.org.uk/about-the-campaign/definitions-and-the-rcm-position-paper

Royal College of Obstetricians and Gynaecologists/Royal College of Midwives (RCOG/RCM). 2006. ‘Immersion in water during labour and birth’. London: Royal College of

Obstetricians and Gynaecologists and Royal College of Midwives.

Russell, K. 2011. ‘Struggling to get into the pool room? a critical discourse analysis of labor ward midwives’ experiences of water birth’, International Journal of Childbirth 1(1), 52-60.

Stark, M.A. & Miller, M.G. 2009. ‘Barriers to the use of hydrotherapy in labor’, Journal of Obstetric, Gynecologic, & Neonatal Nursing 38, 667-675.

Elizabeth Cluett, Ethel Burns

This review includes 12 trials (3243 women).

Water immersion during the first stage of labour significantly reduced epidural/spinal analgesia requirements, without adversely affecting labour duration, operative delivery rates, or neonatal wellbeing.

One trial showed that immersion in water during the second stage of labour increased women’s reported satisfaction with their birth experience.

Further research is needed to assess the effect of immersion in water on neonatal and maternal morbidity.

No trials could be located that assessed the immersion of women in water during the third stage of labour, or evaluating different types of pool/bath.

Background:

Enthusiasts suggest that labouring in water and waterbirth increase maternal relaxation, reduce analgesia requirements and promote a midwifery model of care.

Critics cite the risk of neonatal water inhalation and maternal/neonatal infection.

Objectives:

To assess the evidence from randomised controlled trials about immersion in water during labour and waterbirth on maternal, fetal, neonatal and caregiver outcomes.

Search strategy:

We searched the Cochrane Pregnancy and Childbirth Group’s Trials Register (30 June 2011) and reference lists of retrieved studies.

Selection criteria:

Randomised controlled trials comparing immersion in any bath tub/pool with no immersion, or other non-pharmacological forms of pain management during labour and/or birth, in women during labour who were considered to be at low risk of complications, as defined by the researchers.

Health topics:

Pregnancy & childbirth > Care during childbirth > Normal labour & birth Pregnancy & childbirth > Care during childbirth > Routine intrapartum care
Data collection and analysis:

We assessed trial eligibility and quality and extracted data independently. One review author entered data and the other checked for accuracy.

Main results:

This review includes 12 trials (3243 women): eight related to just the first stage of labour: one to early versus late immersion in the first stage of labour; two to the first and second stages; and another to the second stage only.

We identified no trials evaluating different baths/pools, or the management of third stage of labour.

Results for the first stage of labour showed there was a significant reduction in the epidural/spinal/paracervical analgesia/anaesthesia rate amongst women allocated to water immersion compared to controls (478/1254 versus 529/1245; risk ratio (RR) 0.90; 95% confidence interval (CI) 0.82 to 0.99, six trials).

There was also a reduction in duration of the first stage of labour (mean difference -32.4 minutes; 95% CI -58.7 to -6.13).

There was no difference in assisted vaginal deliveries (RR 0.86; 95% CI 0.71 to 1.05, seven trials), caesarean sections (RR 1.21; 95% CI 0.87 to 1.68, eight trials), use of oxytocin infusion (RR 0.64; 95%CI 0.32 to 1.28,five trials), perineal trauma or maternal infection.

There were no differences for Apgar score less than seven at five minutes (RR 1.58; 95% CI 0.63 to 3.93, five trials), neonatal unit admissions (RR 1.06; 95% CI 0.71 to 1.57, three trials), or neonatal infection rates (RR 2.00; 95% CI 0.50 to 7.94, five trials).

Of the three trials that compared water immersion during the second stage with no immersion, one trial showed a significantly higher level of satisfaction with the birth experience (RR 0.24; 95% CI 0.07 to 0.80).

A lack of data for some comparisons prevented robust conclusions.

Further research is needed.

Authors’ conclusions:

Evidence suggests that water immersion during the first stage of labour reduces the use of epidural/spinal analgesia and duration of the first stage of labour.

There is limited information for other outcomes related to water use during the first and second stages of labour, due to intervention and outcome variability.

There is no evidence of increased adverse effects to the fetus/neonate or woman from labouring in water or waterbirth.

However, the studies are very variable and considerable heterogeneity was detected for some outcomes.

Further research is needed.

Immersion in water for pain relief and the risk of intrapartum transfer among low risk nulliparous women: secondary analysis of the Birthplace national prospective cohort study

Mirjam Lukasse, Rachel Rowe, John Townend, Marian Knight and Jennifer Hollowell

Abstract

Background: Immersion in water during labour is an important non-pharmacological method to manage labour pain, particularly in midwifery-led care settings where pharmacological methods are limited.

This study investigates the association between immersion for pain relief and transfer before birth and other maternal outcomes.

Methods:

A prospective cohort study of 16,577 low risk nulliparous women planning birth at home, in a freestanding midwifery unit (FMU) or in an alongside midwifery unit (AMU) in England between April 2008 and April 2010.

Results:

Immersion in water for pain relief was common; 50% in planned home births, 54% in FMUs and 38% in AMUs.

Immersion in water was associated with a lower risk of transfer before birth for births planned at home (adjusted RR 0.88; 95% CI 0.79–0.99), in FMUs (adjusted RR 0.59; 95% CI 0.50–0.70) and in AMUs (adjusted RR 0.78; 95% CI 0.69–0.88).

For births planned in FMUs, immersion in water was associated with a lower risk of intrapartum caesarean section (RR 0.61; 95% CI 0.44–0.84) and a higher chance of a straightforward vaginal birth (RR 1.09; 95% CI 1.04–1.15).

These beneficial effects were not seen in births planned at home or AMUs.

Conclusions:

Immersion of water for pain relief was associated with a significant reduction in risk of transfer before birth for nulliparous women.

Overall, immersion in water was associated with fewer interventions during labour.

The effect varied across birth settings with least effect in planned home births and a larger effect observed for planned FMU births.

Full article is available to read via the link below and is highly recommended, with some very detailed analysis and insight into methods of study with statistical support.

Please click here to read the full publication

bmc-good-version

The New Zealand College of Midwives (Inc) supports immersion of women in warm water during labour as a method of pain management.

Judy Slome Cohain

originally published December 2010

Abstract: A single case of early onset newborn Group B Strep was documented among 4,432 hospital births into water in the absence of GBS prophylaxis, suggesting that low risk women giving birth into water have a 300% lower rate of newborn GBS disease newborns than dry, full term births delivered by current GBS guidelines.

Possible explanations include:

1) Inoculating the baby with mother’s intestinal flora at birth protects against GBS infection;

2) Bath water washes off the GBS bacteria acquired during the descent through the vagina;

3) Pool dilutes the GBS among a multitude of other intestinal bacteria which compete with GBS;

4) Early onset GBS disease is prevented by lower level of interventions at water birth which promotes maternal and fetal immune function;

5) Kangaroo care after water birth promotes immune function of mother newborn dyad. Much is still to be learned from research documenting birth into water.

Group B Strep (GBS) inhabits the intestines.

Some minutes before the time of birth, the descending fetal head usually causes fecal matter to be excreted. If the woman is in water, the feces enters the water.

A bathtub can be quickly emptied before the fetal head is born.

If she is in a pool, the warm water is likely to be inoculated with GBS. Warm wet conditions enhance the reproduction of bacteria, increasing their numbers exponentially every few minutes.

If the baby’s is born into the warm, feces-exposed water, the baby is exposed to the mother’s intestinal bacteria.

Exposing the baby to the mother’s own natural flora is known to be one of many protective processes that are meant to take place immediately after birth.

Even so, birthing a baby into a feces soiled pool may be considered by many to be likely to increase the risk of newborn infection.

However, evidence of adverse outcomes is lacking.

A report of 4,030 births into water reports no deaths from early onset GBS and one GBS infection.

(1) Information is lacking as to whether the reported GBS-infected baby may also have had a chromosomal abnormality and/or increased blood loss from a snapped umbilical cord or shoulder dystocia.

When this study was conducted, the full term dry birth rate for GBS disease was six times higher (1 in 588) than the waterbirth GBS rate.

The current full term dry birth GBS rate is three times higher (1 in 1,450) than the reported waterbirth rate.(3)

The Cochrane review (2) includes three additional studies tallying another 402 women who birthed their babies into water for which no cases of newborn GBS infection occurred.

The full term waterbirth GBS rate is therefore, a fraction of the dry birth GBS infection rate even after implementation of the US Center for Disease Control (CDC) protocols.

The rate of early onset GBS disease among newborns born before 37 weeks gestation was 1 in 330(3).

Unfortunately research is lacking for whether this rate could also be lowered by birthing into water.

The 2010 CDC Guidelines (5) begins with the statement : “Maternal intrapartum GBS colonization is the primary risk factor for early-onset disease in infants.”

This statement is derived solely from data from interventive land birth, therefore making an incorrect assumption that all births take place in interventive hospital environments.

The evidence regarding GBS and waterbirth is missing from the CDC Guidelines. Objecting to the hospital waterbirth data on the basis of it not being randomized or a small sample is negated by the fact that there are no RCT trials supporting CDC Guidelines(4) and the largest samples included in the new CDC protocols are nonrandomized samples of 5,000 and 7,600 used to
1
support the low rate of anaphylaxis in women given prophylactic antibiotics. ( 5 )
The CDC(5) states definitively that “GBS also can invade through intact membranes (32,33)”.

The words ‘invade through intact membranes’ explicitly describes GBS making a hole rather than a blood borne mechanism.

This statement contradicts a later statement in the same protocols that early newborn GBS infection following elective CS in the presence of intact membranes is either completely or almost non-existant.

The only references supporting GBS ‘invading thru intact membranes’ are from 1984(6) and 1988(7) and do not refer to full term birth.

The first reports on 15 births less than 1000 g, before 28 weeks and all suffering from symptomatic intrauterine infections before birth.

The second reference states: “10-50% of group B streptococcal infections occur in the presence of intact membranes” which is a wild supposition not supported by any other research.

A mechanism is lacking for how GBS might have crossed both the amnion’s and chorion’s thick cross-linkages in the collagen triple helix that provide strength to the collagen.

The compact fibroblast layers of connective tissue beneath the basement membrane form a fibrous barrier. Interstitial collagens predominate and form parallel bundles of collagen fibrils that maintain the mechanical integrity of the amnion.

As an experienced practitioner knows, even with the aid of a sharp amniohook, it can be challenging to break thru two layers of healthy membranes without the presence of a bulging bag of water.

A close examination of CDC guidelines brings into question why certain dubious research is included and other research missing.

While birthing into water may appear counterintuitive, evidence strongly suggests that it protects babies from GBS disease.

Five possible mechanisms for how water birth may protect against GBS disease are suggested in the abstract.

While infusing women with high doses of IV antibiotics to suppress the GBS before the baby passes through, has been widely accepted as current protocol, the Cochrane review emphasizes the lack of RCT studies and the high risk of bias in the 3 small studies that exist. (4)

Routine antibiotic prophylaxis makes light of the biological adaptive abilities of bacteria.

Bacteria have developed many intriguing mechanisms like selectively pumping antibiotics out of their bodies and even digesting antibiotics for nutrition.(8)

The microorganism producing the antibiotic, must have a mechanism to keep itself unharmed by the antibiotic it produces.

Therefore, perfect antibiotic ‘resistance’, a euphemism for immunity, exists before the antibiotic is created.

GBS disease is increasing.

The overall incidence of early onset GBS disease of the newborn showed an initial downward trend from 2000 to 2003 (0.52 to 0.31 cases per 1,000 live births) followed by an increase from 2003 to 2006 (0.31 to 0.40 cases per 1,000 live birth.(9)

Not only is early onset GBS increasing but late onset GBS which is immune to prophylaxis is also increasing above previous levels (2003–2005).(9)

Finally, adult GBS has increased by 32% and it is predicted that this rate will continue to increase.(9)

Seven percent of adults are allergic to penicillin and therefore already have no effective treatment for the 20% of GBS that is erythromycin- and clindamycin- resistant(4).

In addition, a new disease that causes painful vaginal burning sensation without relief for years, called long-term symptomatic GBS vaginitis, first described in case studies in 1997, is now becoming more and more common and likely involves antibiotic resistant strains of GBS, since antibiotics are not consistently useful to eradicate it.(10)

Hospital Birth into Water data appears to provide the lowest Newborn GBS disease outcomes available without increasing the dangers of antibiotic resistance.

References:

1. Gilbert R.E. and P.A. Tookey. 1999. Perinatal mortality and morbidity among babies delivered in water: surveillance study and postal survey. BMJ 319: 483–87.

2. Cluett, E.R. and E. Burns. 2009. Immersion in water in labour and birth. Cochrane Database of Systematic Reviews (2) DOI: 10.1002/14651858.CD000111.pub3.

3. Phares C.R., et al. 2009. Epidemiology of invasive group B streptococcal disease in the United States, 1999-2005. JAMA 299(17): 2056–65.

4. Ohlsson A, Shah VS. Intrapartum antibiotics for known maternal Group B streptococcal colonization. Cochrane Databaseof Systematic Reviews 2009, Issue 3. Art. No.: CD007467.

5. Prevention of Perinatal Group B Streptococcal Disease. Revised Guidelines from CDC. 2010. November 19, 2010/59(RR10);1-32.

6. Desa DJ, Trevenen CL. Intrauterine infections with group B beta-haemolytic streptococci. Br J Obstet Gynaecol 1984;91:237–9.

7. Katz V, Bowes WA Jr. Perinatal group B streptococcal infections across intact amniotic membranes. J Reprod Med 1988;33:445–9.

8.http://www.scientificamerican.com/podcast/episode.cfm?id=166B51F8-DE9C-DCF8- 9132AF8A95CA0642 Accessed 1 Sept 2010.

9. Centers for Disease Control and Prevention. 2009. Trends in perinatal group B streptococcal disease — United States, 2000–2006. MMWR Morb Mortal Wkly Rep 58(5): 109–12.

10. Cohain, J.S. 2009. Long term Symptomatic GBS Vulvovaginitis — eight cases resolved with freshly cut garlic. Eur J Obstet Gynecol Reprod Biol 146(1): 110–11.

8 December 2015:

References

18 February 2016: Midwives Alliance

The MANA and CfM Joint Position Statement on Water Immersion During Labor and Birth is a position paper written for a broad audience including midwives and other birthcare professionals, consumers, doulas, childbirth educators, and policy makers.

It is co-authored by the Midwives Alliance of North America and Citizens for Midwifery.

A year of collaborative work has produced a great educational tool that gives concise access to the research and the wisdom of experience that documents the safety, benefits and recommendations for success.

With over 80 citations, including the new study “Maternal & Newborn Outcomes Following Immersion During Waterbirth” by Bovbjerg, Cheyney and Everson, which utilized data from the MANA Statistics project, and research by waterbirth activist Barbara Harper, the position paper is a reference guide to the evidence for the safety of water immersion during labor and birth.

How does the new study using data from the MANA Statistics project help us better understand waterbirth?

The research of Bovbjerg, Cheyney and Everson helps to dispel some of the more publicized concerns about the safety of waterbirth to the baby, including drowning, cord avulsion and respiratory distress.

No deaths in over 6500 water births were attributable to being born under water. There was also no additional risk of maternal infection or hemorrhage.

The MANA Stats study showed that 35% of over 18,000 home and birth center births occurred in water, demonstrating that the midwives contributing to MANA Stats have considerable experience attending and monitoring births in water.

The experience level of the practitioner may be an important factor in the safety of waterbirth.

6,521 waterbirths, including 13 sets of twins, 29 breeches and 327 VBACs, were compared with 10,252 mothers who did not choose waterbirth, making this the largest comparative study on waterbirth to-date.

Additionally, this is the first large waterbirth study of a US population, with its unique healthcare system and demographics.

While the ACOG/AAP Committee Opinion of April, 2014, not recommending water immersion for birth, acknowledged the limitations of the available research on waterbirth, this large US study fills that gap and gives us the best evidence to-date on the safety of birthing in water.

“Maternal & Newborn Outcomes Following Immersion During Waterbirth” by Bovbjerg et al, was published Jan. 20, 2016 in the Journal of Midwifery & Women’s Health.

JMWH has generously agreed to make this research article open access, so midwives, birth workers, and consumers can read it without needing to buy a subscription to the Journal.

What else can we learn from the MANA/CfM Joint Position Statement?

Evidence and experience show us that mothers choose waterbirth for several reasons.

They report feeling more relaxed, in control, able to move more freely, and, notably, relief from pain.

Especially considering the risks of pharmacologic pain management such as epidural and spinal anesthesia, water immersion during labor and birth may be safer for mother and baby.

“In addition, because water immersion facilitates normal physiologic birth it may also be associated with other beneficial health outcomes for mother and baby, including decreased need for intervention during labor and reduced incidence of surgical/instrumental delivery.”

As in all healthcare and birthcare decisions informed consent/refusal and shared decision making with your care provider is key to determining what is best for each family.

The Joint Position Statement can help in these ways:

• describes the benefits of water immersion for mother and baby,
• suggests how these benefits may improve outcomes for families of color,
• addresses consumer choice and shared decision making,
• considers client values and individual needs and,
• lists factors that promote safety and success.

The practical and professional pearls of wisdom make the Factors that Promote Safety and Success section an invaluable tool when considering and planning a waterbirth and we are pleased to be able to share them with you.

The conclusion:

Many families consider water immersion during labor and birth a valuable option.

Current research and experience show waterbirth to be safe for mothers and babies and may provide benefits to both.

“MANA and CfM support the use of water immersion during labor and birth, and believe it should be made available to birthing families across all settings.

MANA and CfM encourage all care providers to become educated about the safe use of water immersion during labor and birth, and to engage in a shared decision making process when discussing the option of water immersion with their clients.” (quote from the statement)

The authors of the joint position statement are:

Jill Breen, CPM, CLC; Justine Clegg, CPM, LM, MS; Nasima Pfaffl, MA, President CfM; Amy Smith, CPM

Thanks also to the consultants on the statement:

Barbara Harper, RN, CD, CCE; Holly Horan, MA; Jennie Joseph, LM, CPM, CEO of Commonsense Childbirth, Inc.; Indra Lusero, JD, MA; Jeanette McCulloch, IBCLC; Shafia M. Monroe, MPH, DEM, CDT, President and CEO of the International Center for Traditional Childbearing (ICTC).

Leyla Mollamahmutoğlu,1 Özlem Moraloğlu,1 Şebnem Özyer,1 Filiz Akın Su,1 Rana Karayalçın,1 Necati Hançerlioğlu,1Özlem Uzunlar,1 and  Uğur Dilmen2

Objective

To document the practice of labour in water, to assess the effects of water immersion during labor and/or birth (labour stages 1, 2 and 3) on maternal, fetal and neonatal wellbeing and to compare the outcomes and safety with conventional vaginal deliveries and deliveries with epidural analgesia.

Material and Methods

Two-hundred and seven women electing for waterbirth (n=207) were compared with women having conventional vaginal deliveries (n=204) and vaginal deliveries with epidural analgesia (n=191). Demographic data, length of 1st, 2nd and 3rd stage of labor, induction and episiotomy requirements, perineal trauma, apgar scores, NICU requirements and VAS scores were noted.

Results

The 1st stage of labor was shorter in waterbirths compared with vaginal delivery with epidural analgesia but the 2nd and 3rd stage of labor were shortest in patients having waterbirth compared with conventional vaginal delivery and vaginal delivery with epidural analgesia.

Patients having waterbirth had less requirement for induction and episiotomy but had more perineal laceration. All women having waterbirths had reduced analgesia requirements and had lower scores on VAS.

There was no difference in terms of NICU admission between the groups. Apgar scores were comparable in both groups. There were no neonatal deaths or neonatal infections during the study.
Conclusion

The study demonstrates the advantages of labor in water in terms of reduction in 2nd and 3rd stage of labor, reduction in pain and obstetric intervention such as induction or amniotomy.

Introduction

In 1983, Odent published the results of the first hundred water births in The Lancet (1). It was postulated that anxiety and pain may trigger a stress response during labour (2) leading to reduced uterine activity and dystocia (3). Labouring in water may overcome this stress response by aiding relaxation and relief of pain (4).

Zanetti-Daellenbach et al. revealed that water deliveries performed in a selected low risk collective needed less analgesia had a shorter duration of first and second stages of labour, a lower episiotomy rate and were not associated with any adverse maternal or fetal outcome (5).

The advantages of immersion in water during labour and/or birth include reduced pain, increased functional diameter of the true pelvis, increased quality of contractions, increased release of endorphins, decreased need for opiates, increased movement for the mother as well as improved positioning in different stages of labour (6).

There are also studies that have reported the disadvantages associated with water birth which include maternal and neonatal infections, as well as the possibility of respiratory problems for the newborn (7, 8).

Cluett and Burns in a review of 11 trials concluded that water immersion during the first stage of labour reduced the use of epidural/spinal analgesia, but there was limited data for other outcomes related to water use during the first and second stages of labour (9). They also stated that there was no evidence of increased adverse effects on the fetus/neonate or woman from labouring in water (9).

The aim of this study is to document the practice of labour in water, to assess the effects of water immersion during labour and/or birth (labour stages 1, 2 and 3) on maternal, fetal and neonatal wellbeing and to compare the outcomes and safety with conventional vaginal deliveries and deliveries with epidural analgesia.

Materials and Methods

In a prospective clinical trial, the interview and observation techniques were used to study 610 pregnant women who were admitted to Zekai Tahir Burak Women’s Health Education and Research Hospital, between June 2007 and September 2008.

Women electing for water birth (Study Group 1, n=207) were compared with vaginal deliveries with epidural analgesia (Study Group 2, n=191) and women having conventional vaginal deliveries (Control, n=204).

The pregnant women were given comprehensive information on water birth before they were asked to participate in the study. Ethical approval was obtained from the local research ethics committee prior to the study, and written informed consent obtained from all patients.

This study was conducted in accordance with the basic principles of the Helsinki Declaration.

The inclusion criteria were gestational age between 37–42 weeks, no previous history of cesarean section, intact membranes, absence of placental abruption or placenta previa, no malpresentation, normal sized single fetus, and normal results of fetal wellbeing tests. The pregnant women with medical or obstetric risk factors were excluded (n=8).

Women presenting on the delivery suite with painful uterine contractions had an initial cervical assessment. This was taken as the onset of the active phase of labour in all groups. They were assigned to control and two study groups. The women were put in a standardized warm water pool which is large enough to allow the pregnant women move freely.

At the time of delivery the water temperature was set to between 37 and 37.5ºC so that the baby was not stimulated to breathe underwater by the cooler temperature of the pool. Fetal heart monitoring was performed at regular intervals with Doppler or NST. In the second stage of labour, care was taken to ensure the controlled delivery of the head of the fetus.

The newborn was placed gently in the mother’s arms within seconds but without rushing and then the cord clamped and cut. Delivery of the placenta and the membranes was completed outside the pool. After the delivery, the pool was emptied and cleaned with antiseptic solution. Cultures were taken for the determination of pathogenic bacteria.

Demographic data, length of 1st, 2nd and 3rd stages of labor, requirement for induction and episiotomy, perineal trauma, apgar scores, neonatal intensive care unit (NICU) requirements and visual analog scale (VAS) scores were noted on a questionnaire.

The women evaluated their birth experience with the VAS (10 cm long VAS from 1 to 10 corresponding to the amount of pain felt by the woman with number 1 for no pain and with number 10 for dreadful pain).

Statistical analysis

Data were evaluated by SPSS for Windows release 15.0 (Chicago Inc.). To compare groups, we used the Chi-square test for categorical variables, Oneway ANOVA and Bonferroni tests for continuous variables that have normal distribution, Kruskall-Wallis oneway ANOVA for continuous variables that have no normal distribution.

As described, variables, frequencies and percentages were given for categorical variables, Mean±standard deviations and median were given for continuous variables. Alpha=0.05 was accepted as a statistically significant value.

In order to detect±2 percentage point difference in VAS scores between groups, for having alpha=0.05, power=0.97, it was predicted that approximately 200 subjects for each group should be taken (NCSS-Pass Pocket Program was used) (Chow SC et al.) (10).

The study groups consisted of 207 water births (Group 1) and 191 vaginal deliveries with epidural analgesia (Group 2), the control group (Group 3) of 204 patients gave birth by the conventional vaginal delivery method at the hospital. The women in the three groups were matched with respect to age, BMI and gestational age (Table 1).

There were 276 primigravidae and 326 multiparous women having water births (Table 2). The mean age of the women were 26.2±5.1, 26.1±4.5 and 25.5±5.1 respectively (Table 1). The mean cervical dilatation at admission in both group 1 (5.3 cm) and group 2 (4.6 cm) was not significantly different from group 3 (4.7 cm).

The duration of the 1st stage of labour was shortest in the conventional vaginal delivery group whereas the duration of the 2nd and the 3rd stages of labour were shortest in the water birth group (Table 1).

There was a highly significant reduction in the induction and episiotomy requirements in the water birth group (Table 1). VAS scores were the lowest in the water birth group, so there was less analgesia requirement (Table 1).

Conversely, the perineal laceration rate was higher in the water birth group, however most of these lacerations were minimal. Systolic and diastolic blood pressures seem to be lower in the water birth group, however the differences were not clinically significant. The decrease in hemoglobin levels as an indication of blood loss during labour were not statistically significant.

The birthweight of the infants were highest, however Apgar scores were slightly lower in the water birth group. There was no difference in the rates of admissions to the NICU between the groups (Table 1). There were no documented neonatal infections. There was no adverse perinatal outcome or neonatal deaths. All the babies were born in good condition.

When primigravidas and multiparous women having water birth are considered (Table 2), the 1st stage of labour is longer in both groups compared with controls, however the 2nd and 3rd stages of labour were the shortest in both primigravidas and multiparous women labouring in water compared with controls. The need for induction and episiotomy for both primigravidas and multiparous women was lowest in water birth group compared with others.

Perineal laceration rates were higher in both groups compared with controls. VAS scores were lowest in the water birth group in both primigravidas and multiparous women. Apgar scores were slightly lower in the water birth group, however NICU admission rates were not statistically different in the water birth group for both primigravidas and multigravidas.

Discussion

Water births have rapidly become one of the most popular birth methods. There is evidence of use of water immersion as a therapeutic medium for physical and psychological illnesses by the Chinese, Egyptians, Japanese and Assyrians, as well as Greeks and Romans (9).

Water immersion during labour, including birth, used for relaxation and pain relief, has a long history. In 1995, the first international water birth conference was held in London, followed by many researches and conferences.

The positive physiological effects of hydrotherapy can facilitate the neurohormonal interactions of labour, reducing pain, and potentially facilitates the progress of labour (11, 12). Water immersion may be associated with improved uterine perfusion, less painful contractions and a shorter labour with fewer interventions (13–15).

Several reports have shown that water immersion shortens the process of labour (1, 15), however some others found no significant difference for the duration of the 1st stages of labour (13, 16–20). The present study also demonstrates that the 1st stage of labour is not shortened by immersion in water in either primigravidas or multigravidas.

Cammu et al., Eckert et al., Rush et al. and Woodward et al. provided data on analgesia and anesthesia use in their studies and found that there was a significant reduction in the incidence of analgesia and anesthesia use among women placed in water during the first stage of labour (16, 17, 19, 20).

In the present study, we have shown that VAS scores indicating the pain felt by the women were lowest among women having water birth, even lower than the women labouring with epidural analgesia. In agreement with these studies, we observed that immersion in water greatly reduces the pain and need for additional analgesia.

Labouring in water has been found to reduce stress hormones and cathecolamines which inhibit oxytocin and labour progress (9). In our study, the duration of the second stage of labour was found to be shorter in water births, consistent with the results of studies of Chaichian et al. and Otigbah et al. (6, 21).

The fetus may be more likely to adopt a more relaxed and flexed position, because the mother can easily explore different positions to maximise her pelvic diameters (22).

The duration of the 3rd stage of labour, which is the delivery of the placenta, is also significantly reduced after water births. This minimizes amount of blood loss during this period.

The lower blood loss in water births can also be explained by the hydrostatic pressure in the pool, by the less severe lacerations or possibly by a facilitated control of the third stage of labour.

In the study, patients having waterbirth had less requirement for obstetric interventions such as induction and episiotomy but had more perineal lacerations. However, the lacerations in water birth group were less severe than those in epidural analgesia and conventional delivery group.

Otigbah et al. found that primigravidas having water births had less perineal trauma and the overall episiotomy rate was 5 times greater in the control group, but overall, more women having water births had perineal tears (21). On the other hand, there are studies which show no difference in perineal trauma (23, 24).

The reason why women having water births had more tears may be explained by the difficulty in accessing the women’s perineum during birth, resulting in more perineal trauma.

However, the widespread belief that with episiotomies 3rdand 4th degree lacerations are avoided is open to question, because in our study episiotomy rates were lowest after water births, and the lacerations were minimal.

There are some concerns about water birth for the fetus. These are thermoregulation during labour, infection and onset of respiration at birth. As the water temperature of the pool does not exceed the maternal body temperature, fetal hyperthermia and associated cardiovascular and metabolic disturbances will not occur (25). None of the newborns in our study took its first breath in water.

This has been explained by the diving reflex which shows that, when the face or especially the glottis comes in contact with fluid, respiration movements are inhibited. Aspiration will occur only when the diving reflex fails, because of anesthesia or severe asphyxia or because of the inappropriate pool temperature.

When we consider neonatal infection, several reported comparative studies, cohort studies and audits report no increased risk of infection to the newborn (5, 19, 21). This is also confirmed by the study that there were no documented neonatal infections.

Overall, water birth does not cause an increased risk of adverse effects to the fetus/newborn.

In conclusion, the study demonstrates the advantages of water birth in terms of reduction in the duration of the 2nd and 3rd stages of labor, reduction in pain and obstetric intervention such as induction or episiotomy.

Labouring in water significantly reduces pain and the requirement of epidural/spinal analgesia.

It is a management approach which contributes positively to maternal physiological and psychological health by reducing the augmentation which is known to increase the risk of uterine hyperstimulation and fetal hypoxia and by reducing the obstetric interventions which are associated with lower maternal satisfaction.

There is no increased adverse effects to the fetus or labouring women.

Water birth may be an alternative birth method that can be offered in selected patients.

Footnotes

Conflict of interest

No conflict of interest was declared by the authors.

References

1. Odent M. Birth under water. Lancet. 1983;2:1476–7.  [PubMed]
2. Brownridge P. The nature and consequences of childbirth pain. Eur J Obstet Gynecol Reprod Biol. 1995;59:9–15.  [PubMed]
3. De Punzio C, Neri E, Metelli P, Bianchi MS, Venticinque M, Ferdeghini M, et al. The relationship between maternal relaxation and plasma beta-endorphin levels during parturition. J Psychosom Obstet Gynaecol. 1994;15:205–10.  [PubMed]
4. Elizabeth R, Cluett Ruth M, Pickering Kathryn, Getliffe Nigel, James St. George Saunders. Randomised controlled trial of labouring in water compared with standard of augmentation for management of dystocia in first stage of labour. BMJ. 2004;328:314–8. [PMC free article]  [PubMed]
5. Zanetti-Daellenbach RA, Tschudin S, Zhong XZ, Holzgreve W, Lapaire O, Hösli I. Maternal and neonatal infection and obstetrical outcome in water birth. European Journal of Obstetrics & Gynecology and Reproductive Biology. 2007;134:37–43.  [PubMed]
6. Chaichian S, Akhlaghi A, Rousta F, Safavi M. Experience of water birth delivery in Iran. Arch Iran Med. 2009;12:468–71.  [PubMed]
7. Rawal J, Shah A, Stirk F, Mehtar S. Water birth and infection in babies. BMJ. 1994;20:309, 511.[PMC free article]  [PubMed]
8. Geissbühler V, Eberhard J. Experience with water births: a prospective longitudinal study of 9 years with almost 4,000 water births. Gynakol Geburtshilfliche Rundsch. 2003;43:12–8.  [PubMed]
9. Cluett ER, Burns E. Immersion in water in labour and birth. Cochrane Database of Systematic Reviews. 2009;2:CD000111. [PMC free article]  [PubMed]
10. Chow SC, Shao J, Wang H.  Sample Size Calculation in Clinical Research. Second Edition. Chapman & Hall; New York: 2008. pp. 70–4.
11. Ginesi L, Niescierowicz R. Neuroendocrinology and birth 1: stress. British Journal of Midwifery. 1998;6:659–63.
12. Ginesi L, Niescierowicz R. Neuroendocrinology and birth 2: The role of oxytocin. British Journal of Midwifery. 1998;6:791–6.
13. Schorn MN, McAllister JL, Blanco JD. Water immersion and the effect on labor. J Nurse Midwifery. 1993;38:336–42.  [PubMed]
14. Geissbuehler V, Eberhard J. Waterbirths a comparative study. Aprospective study on more than 2,000 waterbirths. Fetal Diagnosis and Therapy. 2000;15:291–300.  [PubMed]
15. Burke E, Kilfoyle A. A comparative study, waterbirth and bed birth. Midwives. 1995;108:3–7.
16. Cammu H, Clasen K, Wettere L, Derde M-P. To bathe or not to bathe during the first stage of labor. Acta Obstet Gynecol Scand. 1994;73:468–72.  [PubMed]
17. Eckert K, Turnbull D, MacLennan A. Immersion in water in the first stage of labour: a randomised controlled trial. Birth. 2001;28:84–93.  [PubMed]
18. Kuusela P, Koivisto A-M, Heinonen PK. Lammin kylpy synnytyksen avautumisvaiheessa. [Warn tub bath during opening phase of labor]. Suomen Laakarilehti. 1998;11:1217–21.
19. Rush J, Burlock S, Lambert K, Loasley-Milman M, Hutchinson B, Enkin M. The effects of whirlpool baths in labour: a randomised controlled trial. Birth. 1996;23:136–43.  [PubMed]
20. Woodward J, Kelly SM. A pilot study for a randomised controlled trial of waterbirth versus land birth. BJOG. 2004;111:537–45.  [PubMed]
21. Otigbah CM, Dhanjal MK, Harmsworth G, Chard T. A retrospective comparison of water births and conventional vaginal deliveries. Eur J Obstet Gynecol Reprod Biol. 2000;91:15–20.  [PubMed]
22. Ohlsson G, Buchhave P, Leandersson U, Nordstrom L, Rydhstrom H, Sjolin I. Warm tub bathing during labor; maternal and neonatal effects. Acta Obstet Gynecol Scand. 2001;80:311–4.  [PubMed]
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24. Church LK. Water birth: one birthing center’s observations. Journal of Nurse-Midwifery. 1989;34:165–70.  [PubMed]
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Paula L Barry, Lean E McMahon, Ruth AM Banks, Ann M Fergus, Deirdre J Murphy

Abtract:

Objective To examine the birth outcomes for women and babies following water immersion for labour only, or for labour and birth.

Background: For women at low risk of childbirth complications, water immersion during labour is a care option in many high income countries.

Our aims were (a) to describe maternal characteristics, intrapartum events, interventions, maternal and neonatal outcomes for all women who used a birthing pool during labour who either had a waterbirth or left the pool and had a landbirth, and for the subgroup of women who had a waterbirth in 19 obstetric units, and (b) to compare maternal characteristics, intrapartum events, interventions, and maternal and neonatal outcomes for women who used a birthing pool with a control group of women who did not use a birthing pool for whom we prospectively collected data in a single centre.

Methods: Prospective observational study in 19 Italian obstetric units 2002-2005.

Participants were: (a) 2,505 women in labour using a birthing pool in 19 obstetric units; and (b) 114 women in labour using a birthing pool and 459 women who did not use a birthing pool in one obstetric unit.

Descriptive statistics were calculated for the sample as a whole and, separately, for those women who gave birth in water. Categorical data were compared using Chi square statistics and continuous data by T-tests.

Results: Overall, 95.6% of women using a birthing pool had a spontaneous vertex delivery, 63.9% of which occurred in water. Half of nulliparas and three quarters of multiparas delivered in water.

Adverse maternal and neonatal outcomes were rare.

There were two cases of umbilical cord snap with waterbirth.

Compared with controls, significantly more women who used a birthing pool adopted an upright birth position, had hands off delivery technique, and a physiological third stage.

Significantly fewer nulliparas had an episiotomy, and more had a second degree perineal tear, with no evidence of a difference for extensive perineal tears.

Conclusions: Birthing pool use was associated with spontaneous vaginal birth.

The increase in second degree tears was balanced by fewer episiotomies.

Undue umbilical cord traction should be avoided during waterbirth.

Click here for PDF of the study

Background: Water immersion during labour can provide benefits including reduced need for regional analgesia and a shorter labour.

However, in the United Kingdom a minority of women use a pool for labour or birth, with pool use particularly uncommon in obstetric-led settings.

Maternity unit culture has been identified as an important influence on pool use, but this and other possible factors have not been explored in-depth.

Therefore, the aim of this study was to identify factors influencing pool use through qualitative case studies of three obstetric units and three midwifery units in the UK.

Methods: Case study units with a range of waterbirth rates and representing geographically diverse locations were selected. Data collection methods comprised semi-structured interviews, collation of service documentation and public-facing information, and observations of the unit environment.

There were 111 interview participants, purposively sampled to include midwives, postnatal women, obstetricians, neonatologists, midwifery support workers and doulas.

A framework approach was used to analyse all case study data.

Results: Obstetric unit culture was a key factor restricting pool use.

We found substantial differences between obstetric and midwifery units in terms of equipment and resources, staff attitudes and confidence, senior staff support and women’s awareness of water immersion.

Generic factors influencing use of pools across all units included limited access to waterbirth training, sociodemographic differences in desire for pool use and issues using waterproof fetal monitoring equipment.

Conclusions: Case study findings provide new insights into the influence of maternity unit culture on waterbirth rates.

Access to pool use could be improved through midwives based in obstetric units having more experience of waterbirth, providing obstetricians and neonatologists with information on the practicalities of pool use and improving accessibility of antenatal information.

In terms of resources, recommendations include increasing pool provision, ensuring birth room allocation

Click here for PDF of the study

Background: There is limited research examining midwives’ education, knowledge and practice around immersion in water for labour or birth. Our aim was to address this gap in evidence and build knowledge around this important topic.

Methods: This mixed method study was performed in two phases, between August and December 2016, in the birth centre of a tertiary public maternity hospital in Western Australia.

Phase one utilised a cross sectional design to examine perceptions of education, knowledge and practice around immersion in water for labour or birth through a questionnaire.

Phase two employed a qualitative descriptive design and focus groups to explore what midwives enjoyed about caring for women who labour or birth in water and the challenges midwives experienced with waterbirth.

Frequency distributions were employed for quantitative data. Thematic analysis was undertaken to extract common themes from focus group transcripts.

Results: The majority (85%; 29 of 34) of midwives surveyed returned a questionnaire.

Results from phase one confirmed that following training, 93% (27 of 29) of midwives felt equipped to facilitate waterbirth and the mean waterbirths required to facilitate confidence was seven.

Midwives were confident caring for women in water during the first, second and third stage of labour and enjoyed facilitating water immersion for labour and birth.

Finally, responses to labour and birth scenarios indicated midwives were practicing according to state-wide clinical guidance.

Phase two included two focus groups of seven and five midwives.

Exploration of what midwives enjoyed about caring for women who used water immersion revealed three themes: instinctive birthing; woman-centred atmosphere; and undisturbed space.

Exploration of the challenges experienced with waterbirth revealed two themes: learning through reflection and facilities required to support waterbirth.

Conclusions: This research contributes to the growing knowledge base examining midwives’ education, knowledge and practice around immersion in water for labour or birth.

It also highlights the importance of exploring what immersion in water for labour and birth offers midwives, as this research suggests they are integral to sustaining waterbirth as an option for low risk women.

Click here for PDF of the study

Background: There is a gap in knowledge and understanding relating to the experiences of women exposed to the opportunity of waterbirth.

Our aim was to explore the perceptions and experiences of women who achieved or did not achieve their planned waterbirth.

Methods: An exploratory design using critical incident techniques was conducted between December 2015 and July 2016, in the birth centre of the tertiary public maternity hospital in Western Australia. Women were telephoned 6 weeks post birth.

Demographic data included: age; education; parity; and previous birth mode.

Women were also asked the following: what made you choose to plan a waterbirth?; what do you think contributed to you having (or not having) a waterbirth?; and which three words would you use to describe your birth experience?

Frequency distributions and univariate comparisons were employed for quantitative data.

Thematic analysis was undertaken to extract common themes from the interviews.

Results: A total of 31% (93 of 296) of women achieved a waterbirth and 69% (203 of 296) did not. Multiparous women were more likely to achieve a waterbirth (57% vs 32%; p < 0.001).

Women who achieved a waterbirth were less likely to have planned a waterbirth for pain relief (38% vs 52%; p = 0.24).

The primary reasons women gave for planning a waterbirth were: pain relief; they liked the idea; it was associated with a natural birth; it provided a relaxing environment; and it was recommended.

Two fifths (40%) of women who achieved a waterbirth suggested support was the primary reason they achieved their waterbirth, with the midwife named as the primary support person by 34 of 37 women.

Most (66%) women who did not achieve a waterbirth perceived this was because they experienced an obstetric complication.

The words women used to describe their birth were coded as: affirming; distressing; enduring; natural; quick; empowering; and long.

Conclusions: Immersion in water for birth facilitates a shift of focus from high risk obstetric-led care to low risk midwifery-led care.

It also facilitates evidence based, respectful midwifery care which in turn optimises the potential for women to view their birthing experience through a positive lens.

Click here for a PDF of the study

Aims: To gather, quality assess, synthesize and interpret the views, feeling, and experiences of women who used water immersion during labour and/or birth.

Design: A systematic meta-thematic synthesis and GRADE-CERQual.

Data sources: We searched MEDLINE, CINHAL, PsychINFO, AMED, EMBASE (MIDIRS only), LILACS, AJOL. Additional searches were carried out using Ethos (thesis database), cross-referencing against Google Scholar and citation chasing. Searches were carried out in August 2019, updated February 2020.

Methods: Studies that met the selection criteria were appraised for quality. Data were extracted from the studies using meta-thematic analytical techniques; coding, descriptive findings, and analytical findings. The descriptive findings were subjected to confidence assessments using GRADE-CERQual.

Results: Seven studies met the inclusion criteria. Nine key statements of findings were generated – one had high confidence, three moderate, three low and one very low confidence in the findings. The analytical findings generated three main themes: Liberation and Self-Emancipation, Synergy, transcendence and demarcation and Transformative birth and beyond. Overall, women experienced warm water immersion during labour and/or birth positively. Both the water and pool itself, facilitated women’s physical and psychological needs during labour and/or birth, including offering effective analgesia. Our findings indicated that birthing pools are versatile tools that provide for a space that women can adapt and influence to best suit their individual needs.

Conclusion: Women who used warm water immersion for labour and/or birth describe liberating and transformative experiences of welcoming their babies into the world. They were empowered, liberated, and satisfied. We recommend maternity professionals and services offer water immersion as a standard method of pain relief during labour/birth.

Impact: Understanding women’s experiences of labour and birth will inform future clinical practice. Midwives are optimally positioned to enhance women’s access to water immersion. These findings have implications for education, guideline, and policy development as well as clinical practice.

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Water birth is widely available in English maternity settings for women who are not at increased risk of complications during labour. Immersion in water during labour is associated with a number of maternal benefits.

However for birth in water the situation is less clear, with conclusive evidence on safety lacking and little known about the characteristics of women who give birth in water.

This retrospective cohort study uses electronic data routinely collected in the course of maternity care in England in 2015–16 to describe the proportion of births recorded as having occurred in water, the characteristics of women who experienced water birth and the odds of key maternal and neonatal complications associated with giving birth in water.

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