Immersion in water for labour and birth – Cluett and Burns

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 methods—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.

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.

1990 Sheila Kitzinger, Ethel Burns & Joyce Timms sit around the  first Water Birth Pool installed in NHS Hospital at the John Radcliffe Hospital

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.

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Michel Odent – the birthing pool test

This article first appeared in Midwifery Today, Issue 115, Autumn 2015.

There are many reasons to avoid last-minute cesarean sections that are decided at a phase of real emergency.

They are usually preceded by signs of fetal distress and they are often performed in poor technical conditions.

Furthermore, they are associated with negative long-term outcomes.

For example, according to an American study, women with a full-term second stage cesarean have a spectacular increased rate of subsequent premature births (13.5%) compared to a first-stage cesarean (2.3%) and to the overall national rate (7–8%) (Levine et al. 2014).

There are also serious reasons to avoid prolonged pharmacological assistance during labor, since the probable long-term effects of its different components (particularly drips of synthetic oxytocin) have never been evaluated through valuable scientific studies.

When a woman enters the pool in hard labor, there is an immediate pain relief, and therefore an immediate reduction in the levels of stress hormones.

Since stress hormones and oxytocin are antagonistic, the main short-term response is usually a peak of oxytocin and therefore a spectacular progress in the dilation.

We must add reasons to avoid, when it is possible, prelabor cesareans.

Apart from impaired lung maturation, it appears that the state of stress deprivation associated with “birth without labor” has a great variety of effects on the child, such as a lack of maturation of its olfactory sense (Varendi, Porter and Winberg 2002), which is a guide towards the nipple as early as the hour following birth (Odent 1977; Odent 1978).

Low levels of specific informational substances in the blood of stress-deprived neonates suggest effects on metabolic pathways and development of certain brain structures (Hermansson, Hoppu and Isolauri 2014; Simon-Areces et al. 2012).

It appears also that the milk microbiome and the gut flora of infants are disturbed in a specific way after birth by prelabor cesareans (Azad et al. 2013; Dogra et al. 2015), which is the mode of medicalized birth that disturbs breastfeeding more than all others (Prior et al. 2012; Zanardo et al. 2012).

Unexpectedly, it has been revealed recently that the risk of placenta previa in subsequent pregnancies is statistically significant only if the cesarean has been performed before the labor starts (Downes et al. 2015).

Finally, we are reaching a phase in the history of midwifery and obstetrical practices when an in-labor non-emergency cesarean appears in many cases as the best alternative to drugless childbirth.

In such a context, we understand the need for a new generation of tests in order to decide early enough during labor that the vaginal route is acceptable, without waiting for the phase of real emergency (Odent 2004).

The Basis for the Birthing Pool Test

The birthing pool test is the typical example of a tool adapted to futuristic strategies. It is based on a simple fact.

When a woman in hard labor enters the birthing pool and gets immersed in water at the temperature of the body, a spectacular progress in the dilation is supposed to occur within an hour or two.

If the already well-advanced dilation remains stable in spite of water immersion, privacy (no camera!) and dim light, one can conclude that there is a major obstacle. There is no reason for procrastinations. It is wiser to perform right away an in-labor non-emergency cesarean.

In the early 1980s, I had already mentioned in a mainstream medical journal (Odent 1983) the reason why we originally introduced the concept of birthing pools in the context of a French state hospital.

I had also described the most typical scenario: “We tend to reserve the pool for women who are experiencing especially painful contractions (lumbar pain, in particular), and where the dilatation of the cervix is not progressing beyond about 5 cm. In these circumstances, there is commonly a strong demand for drugs.

In most cases, the cervix becomes fully dilated within 1 or 2 hours of immersion…” At that time, I could only refer to most cases.

Afterwards, I analyzed the outcomes in the rare cases when the dilation had not progressed after an hour or two in the bath. I realized that finally a cesarean had always been necessary, more often than not after long and difficult first and second stages.

This is how I started to tacitly take into account what I had not yet called the birthing pool test.

More recently it happened that I mentioned the birthing pool test during information sessions for doulas.

This is how I learned from a series of reports about births in London hospitals.

It is obvious that many long and difficult labors with the usual range of drugs preceding an emergency cesarean would be avoided if the birthing pool test had been interpreted.

One of these anecdotes is particularly significant.

A woman in hard labor arrived in a maternity unit with her doula while the dilation of the cervix was already well advanced.

Soon after, she entered the birthing pool.

More than an hour later, the dilation had not progressed.

The doula, who was aware of the birthing pool test, was adamant that this woman could not safely give birth by the vaginal route.

A senior doctor was eventually called and diagnosed a brow presentation.

A brow presentation is difficult to diagnose in early labor and is incompatible with the vaginal route. In this case, the doula knew that a cesarean would be necessary, although she could not explain why.

The birthing pool test implies that an internal exam has been performed just before immersion so that, if necessary, a comparison will become possible after an hour or two.

This is an important practical detail, because midwives who are familiar with undisturbed and unguided births in silence, semi-darkness and privacy usually can follow the progress of labor with other criteria than a repeated evaluation of the dilation of the cervix.

Today, we can offer a physiological scenario explaining why immersion in warm water (set to the temperature of the body) makes the contractions more effective during a limited period of time.

When a woman enters the pool in hard labor, there is an immediate pain relief, and therefore an immediate reduction in the levels of stress hormones.

Since stress hormones and oxytocin are antagonistic, the main short-term response is usually a peak of oxytocin and therefore a spectacular progress in the dilation.

After that, there is a long-term complex response, which is a redistribution of blood volume.

This is the standard response to any sort of water immersion.

There is more blood in the chest (Norsk and Epstein 1988).

When the chest blood volume is increased, certain specialized cells in the atria release a peptide commonly called ANP (atrial natriuretic peptide) that interferes with the activity of the posterior pituitary gland (Gutkowska, Antunes-Rodrigues and McCann 1997).

We can all observe the effects of a reduced activity of our posterior pituitary gland after being in a bath for a while: we pass more urine.

This means that the release of vasopressin—a water retention hormone—is reduced.

In fact, the chain of events is not yet completely clarified (Mukaddam-Daher et al. 2002).

We have recently learned that oxytocin—the love hormone—has receptors in the heart (!) and that it is a regulator of ANP (Gutkowska et al. 1997).

In practice, we need to remember that the immediate peak of oxytocin following immersion in warm water will induce a feedback mechanism and eventually the uterine contractions will become less effective after an hour or two.

References:

  • Azad, MB, et al. 2013. “Gut Microbiota of Healthy Canadian Infants: Profiles by Mode of Delivery and Infant Diet at 4 Months.” CMAJ 185 (5): 385–94.
  • Dogra, S, et al. 2015. “Dynamics of Infant Gut Microbiota Are Influenced by Delivery Mode and Gestational Duration and Are Associated with Subsequent Adiposity.” MBio 6 (1): e02419–14.
  • Downes, KL, et al. 2015. “Previous Prelabor or Intrapartum Cesarean Delivery and Risk of Placenta Previa.” Am J Obstet Gynecol 212 (5): 669 e1–6.
  • Gutkowska, J, J Antunes-Rodrigues and S McCann. 1997. “Atrial Natriuretic Peptide in Brain and Pituitary Gland.” Physiol Rev 77 (2): 465–515.
  • Gutkowska, J, et al. 1997. “Oxytocin Releases Atrial Natriuretic Peptide by Combining with Oxytocin Receptors in the Heart.” Proc Natl Acad Sci USA 94 (21): 11,704–09.
  • Hermansson, H, U Hoppu and E Isolauri. 2014. “Elective Caesarean Section Is Associated with Low Adiponectin Levels in Cord Blood.” Neonatology 105 (3): 172–74.
  • Levine, LD, et al. 2014. “Does Stage of Labor at Time of Cesarean Affect Risk of Subsequent Preterm Birth?” Am J Obstet Gynecol 212 (3): 360 e1–7.
  • Mukaddam-Daher, S, et al. 2002. “Regulation of Cardiac Oxytocin System and Natriuretic Peptide during Rat Gestation and Postpartum.” J Endocrinol 175 (1): 211–16.
  • Norsk, P, and M Epstein. 1985. “Effects of Water Immersion on Arginine Vasopressin Release in Humans.” J Appl Physiol 64 (1): 1–10.
  • Odent, Michel. 1977. “The Early Expression of the Rooting Reflex.” In Proceedings of the 5th International Congress of Psychosomatic Obstetrics and Gynaecology, Rome 1977. 1117–19. London: Academic Press.
  • ———. 1978. “L’expression précoce du réflexe de fouissement.” In Les cahiers du nouveau-né, vol. 1–2, edited by E Herbinet. 169–85. Paris: Stock.
  • ———. 1983. “Birth Under Water.” Lancet 2 (8365–66): 1476–77.
  • ———. 2004. The Caesarean. London: Free Association Books.
  • Prior, E, et al. 2012. “Breastfeeding after Cesarean Delivery: A Systematic Review and Meta-analysis of World Literature.” Am J Clin Nutr 95 (5): 1113–35.
  • Simon-Areces, J, et al. 2012. “UCP2 Induced by Natural Birth Regulates Neuronal Differentiation of the Hippocampus and Related Adult Behavior.” PLoS ONE 7 (8): e42911.
  • Varendi, H, RH Porter and J Winberg. 2002. “The Effect of Labor on Olfactory Exposure Learning within the First Postnatal Hour.” Behav Neurosci 116 (2): 206–11.
  • Zanardo, V, et al. 2012. “Impaired Lactation Performance Following Elective Delivery at Term: Role of Maternal Levels of Cortisol and Prolactin.” J Matern Fetal Neonatal Med 25 (9): 1595–98.

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A landmark in the history of water birth – Michel Odent

August 21, 1999 should be remembered as a landmark in the history of water birth.

On that day the British Medical Journal published an unprecedented study about “the perinatal mortality and morbidity among babies delivered [sic] in water” (1).

This study is authoritative for several reasons:

  • The conclusions are based on large numbers: the authors traced the 4,032 babies born
    under water in England and Wales between April 1994 and March 1996.
  • The authors belong to a prestigious department of epidemiology and public health
    (Institute of Child Health, London, United Kingdom).
  • The report has been published in a respected peer review medical journal.

Methods

In order to convince anyone of the seriousness of this study, all midwives should be aware of the sophisticated methods used by the London epidemiologists.

Several inquiries were combined in order to eliminate the effects of under-reporting.

From April 1994 to April 1996, all 1,500 consultant pediatricians in the British Isles were surveyed each month by the “British Paediatric Surveillance Unit” and asked to report whether or not they knew of any births that met the case definition of “perinatal death or admission for special care within 48 hours of birth following labour or delivery in water.”

The findings were compared with reports to the confidential inquiry into stillbirths and death in infancy (a mandatory notification scheme).

At the same time a postal questionnaire was sent to all National Health Service (NHS) maternity units in England and Wales in 1995 and again in 1996 to determine the total number of deliveries in water during the study period.

Results

The main results can be easily summarized and remembered.

There were five perinatal deaths among 4,032 births in water; that is a rate of 1.2 per 1,000. In the context of the United Kingdom this rate is similar for low risk deliveries that do not take place in water.

Furthermore, none of these five deaths were attributable to delivery in water: one stillbirth was diagnosed before immersion; another stillbirth occurred after a concealed pregnancy and unattended homebirth with no previous prenatal care; one baby died aged three days with neonatal herpes infection; one died aged thirty minutes with an intracranial hemorrahage after precipitate delivery; and another one, who died aged eight hours, was found to have hypoplastic lungs at postmortem examination.

There were thirty-four babies admitted for special care; that is a rate of 8.4 per 1,000.

Rates of admission for special care of babies born to low risk primiparous women are significantly higher than for babies born in water.

Birth in water may have caused water aspiration in two babies.

Comments

Compared with well known anecdotes, such as one case of neonatal polycythemia reported in The Lancet in 1997(2), this survey of more than 4,000 babies born (rather than delivered!) in water has been paradoxically ignored by the media, the medical circles and the natural childbirth movement as well.

However, it undoubtedly represents a landmark in the history of the use of water during labour.

From now on midwives should not be the prisoners of strict protocols.

Updated flexible guidelines should accept that “in any hospital where a pool is in daily use a birth under water is bound to happen now and then”(3).

Midwives are far less anxious and invasive wherever a birth under water is considered acceptable if the woman does not have the time or is reluctant to get out of the water during a powerful “fetus ejection reflex.”

The first effect of this study should be to change the focus.

An opportunity is given to recall that the main reason for the birthing pools is to facilitate the birth process and to reduce the need for drugs and other intervention.

In order to control the current epidemic of epidurals the point is to divulge a small number of simple updated recommendations in order to make the most effective use of birthing pools.

Updated recommendations

The main recommendations are based on the fact that immersion in water at the temperature of the body tends to facilitate the birth process during a limited length of time (in the region of an hour or two).

This simple fact is confirmed by clinical observation and by the results of a Swedish randomised controlled study suggesting that women who enter the bath at five centimetres or after (“late bath group”) have a short labour and a reduced need for oxytocin administration and epidural analgesia (4).

Physiologists can offer interpretations.

The common response to immersion is a redistribution of blood volume (more blood in the chest) that stimulates the release by specialized heart cells of the atrial natriuretic peptide (ANP).

The inhibitory effect of ANP on the activity of the posterior pituitary gland is slow, in the region of one to two hours (5).

When a woman is in labour this inhibitory effect is preceded by an analgesic effect that is associated with lower levels of stress hormones and increased release of oxytocin.

Furthermore it is partly via a release of oxytocin that the redistribution of blood volume stimulates the specialized heart cells.

The first practical recommendation is to give great importance to the time when the laboring woman enters the pool.

Experienced midwives have many tricks at their disposal to help women be patient enough so that they can ideally wait until five centimetres dilation.

A shower, that more often as not implies complete privacy, is an example of what the midwife can suggest while waiting.

The BMJ survey clearly indicates that many women stay too long in the bath (the average time was in the region of three hours for women who gave birth in water!).

One reason is that many of them enter the bath long before five centimetres.

The second recommendation is to avoid planning a birth under water.

When a woman has planned a birth under water she may be the prisoner of her project; she is tempted to stay in the bath while the contractions are getting weaker, with the risk of long second and third stages.

There are no such risks when a birth under water follows a short series of irresistible contractions.

The recommendations regarding the temperature should not be overlooked.

It is easy to check that the water temperature is never above 37° C (the temperature of the maternal body).

Two cases of neonatal deaths have been reported after immersion during labor in prolonged hot baths (39.7° C in one case) (6).

The proposed interpretation was that the fetuses had reached high temperatures (the temperature of a fetus is 1° higher than the maternal temperature) and could not meet their increased needs in oxygen.

The fetus has a problem of heat elimination.

At the dawn of a new phase in the history of childbirth one can anticipate that, if a small number of simple recommendations are taken into account, the use of water during labor will seriously compete with epidural anesthesia.

Then helping women to be patient enough and enter the pool at the right time will appear as a new aspect of the art of midwifery.

Michel Odent, MD founded the Primal Health Research Centre in London and developed the maternity unit in Pithiviers, France, where birthing pools are used. He is the author of ten books published in twenty languages. Two of them—Birth Reborn and The Nature of Birth and Breastfeeding—were published originally in the United States. His most recent book is The Caesarean.

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Joint statement: Immersion in water during labour and birth – RCOG RCOM

Royal College of Obstetricians and Gynaecologists/Royal College of Midwives

Joint statement No.1 Immersion in water during labour and birth

Originally published: 2006

Summary

1.  Both the Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives support labouring in water for healthy women with uncomplicated pregnancies.

The evidence to support underwater birth is less clear but complications are seemingly rare.

If good practice guidelines are followed in relation to infection control, management of cord rupture and strict adherence to eligibility criteria, these complications should be further reduced.

Background

  1. Lying in warm water gives a sense of relaxation, but whether it actually reduces pain is less certain. A perception of relaxation, pain relief, ease of movements and more holistic experience made labour in water a popular choice during the 1980s. This concept has been extended to include actual birth under water following widely quoted experience from France.1 In response to public demand, the Winterton Report recommended that all maternity services provide women with the option to labour and/or give birth in water.2
  2. Recent surveys3 show that, of 295 UK maternity units for which data on birthing pools were available, 64% had at least one birthing pool, with 20 units having two or more. There are no current data on the number of women who actually use these facilities during labour or for water birth, apart from a postal survey carried out between April 1994 and March 1996, which reported that, at that time, fewer than 1% of births in England and Wales occurred in water.4
  3. Partly in response to the Winterton Report, the Royal College of Obstetricians and Gynaecologists produced a Statement on birth in water in 1994, which was updated in 20015 and the Royal College of Midwives published a Position Paper on the use of water in labour and birth in 1994 (updated in 2000).6 Both documents endorsed the use of water in labour as a choice, provided that attendants had appropriate skills and confidence to assist women who choose to labour or give birth in water.

Labouring in water

  1. It is important to separate the evidence on benefits and risks of immersion in water during the active phase of labour from those of actual birth in water.
  2. There are considerable perceived benefits of using immersion in water during labour, including less painful contractions and less need for pharmacological analgesia, shorter labour, less need for augmentation, with no known adverse effects for the woman herself.However, there may be rare but clinically significant risks for the baby born under water. These include respiratory problems (including the possibility of fresh water drowning), cord rupture with haemorrhage, and waterborne infections.
  1. A Cochrane review by Cluett et al.7 provides the most recent evidence on water births. Overall, there was no difference found in the use of analgesia, although women allocated to immersion in water needed less epidural, spinal or paracervical analgesia. There was no significant difference in other important clinical outcomes, including duration of labour, operative delivery and perineal trauma. The same applied to the neonatal outcomes, including neonatal infection, which was rare.
  2. The evidence on timing of immersion into water during the first stage of labour was not robust enough to set criteria8 but early labour could be managed by mobilisation and other activities within a labour room rather than water immersion.
  3. Most of the available evidence, both randomised and observational, is restricted to healthy women with uncomplicated pregnancy at term, although induction of labour and previous caesarean section have been managed using water for labour and birth without reported problems.9 A randomised trial by Cluett et al.10 on women with prolonged labour found reduction in obstetric intervention following immersion in water but a higher number of babies who needed admission to the neonatal unit. Although there is clearly a need for more research, the currently available evidence does not justify discouraging women from choosing immersion in water during labour. Increasing women’s choices for analgesia and the need for maternity services to promote normality are key principles in all UK Maternity Service Framework documents and support provision of birthing pools to be made available for healthy women with uncomplicated pregnancies.11–13

Birth in water

  1. Informed choice on the benefits and risks of birth in water is clouded by the lack of good quality safety data. Although there is no evidence of higher perinatal mortality or admission to special care baby units (SCBUs) for birth in water,4,14,15 caution is advised because of small numbers, possible under-reporting of SCBU admission and exclusion of women who were in labour in water but gave birth conventionally after complications.
  2. One review identified 16 articles reporting a total of 63 neonatal complications attributable to water birth, including drowning, respiratory problems, cord avulsion and waterborne infections.16 One can argue that this anecdotal evidence is reassuring, given the thousands of women who have given birth under water in the last few decades. However, we still do not know how the low perinatal mortality and morbidity rates compare with those babies born in air.
  3. The respect for maternal autonomy and choice is important; however, it is important that any possible concerns for fetal and neonatal safety are made clear. Women who make an informed choice to give birth in water should be given every opportunity and assistance to do so by attendants who have appropriate experience. More research is needed on third-stage management in the pool, as there is currently no reliable evidence that can be used to inform women regarding the benefits and risks of experiencing the third stage of labour under water.

Achieving best practice

13 Both the Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives believe that to achieve best practice with water birth it is necessary for

Royal College of Obstetricians and Gynaecologists and Royal College of Midwives Joint Statement No.1 2 of 5 organisations to provide systems and structures to support this service.

This means developing a service that is committed to responsive practices and ensuring that women are involved in planning their own care with information, advice and support from professionals.11–13

Inclusion and exclusion criteria

14 All healthy women with uncomplicated pregnancies at term should have the option of water birth available to them and should be able to proceed to a water birth if they wish. The written documentation of any discussion is essential.

Practice issues

  1. There has been much controversy over the temperature of the water of a birthing pool, with strict criteria recommending differing estimates ranging from 34 to 37 degrees Celsius17 to a Swedish study which recommended that women be encouraged to regulate the temperature of the water to suit themselves.18 Given these large discrepancies, it would be difficult to agree strict temperature restrictions. It may be of more benefit to allow women to regulate the pool temperature to their own comfort and encourage them to leave and re-enter the pool in the first stage of labour as and when they wish. Birth attendants should ensure that the ambient room temperature is comfortable for the woman and should encourage her to drink to avoid dehydration. Cord clamps should be readily available and birth attendants need to be alert to the possibility of occult cord rupture and be sensitive to any undue tension on the cord.16
  2. Monitoring of the fetal heart using underwater Doppler should be standard practice, as stated in the current National Institute for Health and Clinical Excellence guidelines.19 If there are any concerns about maternal or fetal wellbeing, the woman should be advised to leave the birthing pool and an opinion from an obstetrician or other suitably qualified person should be sought in the usual manner. There needs to be a locally agreed procedure for getting a woman out of the pool, should she become compromised, and all staff likely to be caring for the woman in the room must be familiar with the procedure and should practice it regularly in emergency drills.
  3. If the woman raises herself out of the water and exposes the fetal head to air, once the presenting part is visible, she should be advised to remain out of the water to avoid the risk of premature gasping under water.
  4. All birthing pools and other equipment (such as mirrors and thermometers) should be disposed of or thoroughly cleaned and dried after every use, in accordance with local infection control policies. Disposable sieves should be made available to ensure that the pool remains free from maternal faeces and other debris. Local information and guidelines regarding prevention of legionella build up in water supply from seldomly used pools should be obtained from local NHS trust estates and should be adhered to. Midwives should use universal precautions and follow local trust infection control guidelines.

Education, skills and training

19 Midwives should discuss antenatally the use of immersion in water in labour with all women in a low-risk category, as part of their overall discussions regarding options for pain relief, and information leaflets should be available. It is important that information on water birth is conveyed to all women in a form they can understand and in a culturally sensitive fashion, to ensure parity of access to quality services.

Royal College of Obstetricians and Gynaecologists and Royal College of Midwives Joint Statement No.1 3 of 5

  1. All midwives should ensure that they are competent to care for a woman who wishes to have a water birth and have a good understanding of the basic principles of caring for a woman in labour, and should make themselves aware of local policies and guidelines. Apart from emergency drills, training should also include emergency management of cord rupture at birth.20
  2. Midwives, managers and supervisors of midwives should ensure that training in caring for a woman who wishes to have a water birth is undertaken by midwives who undertake intrapartum care, in order to increase choice for women and promote normality and ensure quality care.11,21,22

Audit

  1. The use of birthing pools for labour and birth should be audited carefully. Data should be kept both on immersion in first stage of labour for analgesia use and separately for underwater birth. Data collected should focus on maternal wellbeing and the condition of the baby at birth, and should include usual birth outcomes, incidence of cord rupture and reasons for and rates of neonatal admission to SCBU.
  2. Data should also identify women who wanted a water birth but were transferred to conventional birth, including decision time to leave the pool for the birth of baby, the reasons for transferring to conventional care and the condition of mother and baby at transfer.
  3. Data should also be collected on women who wished to use the birthing pool but for whatever reason were unable to do so. Units should also audit ethnicity in relation to the offer of the option of water birth, to ensure that there is parity of access.

Record keeping

25 Accurate contemporaneous records should be kept, as usual. In addition, times of entering and leaving the pool should be clearly documented, including the reason for leaving the pool, if appropriate. It is important that it is recorded clearly whether the baby was born under water.

User surveys

26 User surveys of satisfaction with water birth services, including ease of access and the quality of the information given, should be carried out. Cultural acceptability needs to be reviewed to ensure equity of access and culturally sensitive services.

References

  1. Odent M. Birth under water. Lancet 1983;2:1476–7.
  2. House of Commons Health Committee. Second Report on the Maternity Services (Winterton report). London: HMSO; 1992.
  3. Dr Foster Good Birth Guide [www.drfoster.co.uk/home/birth2005.asp].
  4. Gilbert RE, Tookey PA. Perinatal mortality and morbidity among babies delivered in water: surveillance study and postal survey. BMJ 1999;319:483–7.
  5. Royal College of Obstetricians and Gynaecologists. Birth in Water. RCOG Statement. London: RCOG; 2001.
  6. Royal College of Midwives. The Use of Water in Labour and Birth. Position Paper no. 1a. London: RCM; 2000 [www.rcm.org.uk/data/info_centre/data/position_papers.htm].
  7. Cluett ER, Nikodem VC, McCandlish RE, Burns EE. Immersion in water in pregnancy, labour and birth. Cochrane Database Syst Rev. 2004;(2):CD000111.
  8. Eriksson M, Mattson L, Ladfors L. Early or late bath during the first stage of labour: a randomised study of 200 women. Midwifery 1997;13:146–8.

Royal College of Obstetricians and Gynaecologists and Royal College of Midwives Joint Statement No.1 4 of 5

  1. Brown L. The tide has turned: audit of water birth. Br J Midwifery 1998;6:236–43.
  2. Cluett ER, Pickering RM, Getliffe K, St George Saunders NJ. Randomised controlled trial of labouring in water compared with standard management of dystocia in first stage of labour. BMJ 2004;328:314.
  3. Department of Health. The National Service Framework for Children and Young People. Maternity Services. Standard 11. (NSF) 2004. London: Department of Health [www.dh.gov.uk/assetRoot/04/09/05/23/04090523.pdf].
  4. Scottish Executive. A Framework for Maternity Services in Scotland. Edinburgh: Scottish Executive; 2001 [www.scotland.gov.uk/library3/health/ffms-00.asp].
  5. Welsh Assembly Children’s Health and Social Care Directorate. National Service Framework for Children, Young People and Maternity Services in Wales. Cardiff: Welsh Assembly Government; 2005 [www.wales.nhs.uk/sites/documents/441/ACFD1F6.pdf].
  6. Woodward J, Kelly SM. A pilot study for a randomised controlled trial of water birth versus land birth. BJOG 2004;111:537–45.
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  9. Anderson T. Time to throw the waterbirth thermometers away. MIDIRS 2004;14(3):370–4.
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No evidence that water birth poses harm to newborns, new OSU study finds 

22 January 2106: Oregon State University

CORVALLIS, Ore. – There is no evidence that water births, where a baby is intentionally born under water in a tub or pool, poses any increased harm to the child, Oregon State University researchers have found.

Researchers examined outcome data for more than 6,500 midwife-attended water births in the United States and found that newborns born in water were no more likely to experience low Apgar scores, require transfer to the hospital after birth or be hospitalized in their first six weeks of life, than newborns who were not born in water.

The results were published this week in the Journal of Midwifery and Women’s Health. The study is believed to be the largest study of water births to date and the first to examine the practice in the United States, said lead author, Marit Bovbjerg, an epidemiology instructor in the College of Public Health and Human Sciences at OSU.

“The findings suggest that water birth is a reasonably safe, low-intervention option for women who face a low risk of complications during the birthing process,” Bovbjerg said. “These are decisions that should be made in concert with a medical professional.”

Co-authors of the study are Melissa Cheyney, a medical anthropologist and associate professor in OSU’s College of Liberal Arts, and Courtney Everson, a former OSU graduate student who recently completed her doctorate.

For the study, researchers analyzed birthing outcome data collected from 2004 through 2009 by the Midwives Alliance of North America Statistics Project, commonly referred to as MANA Stats.

Most of the nearly 17,000 women in the study were attended by Certified Professional Midwives, who provided detailed reports on their cases from their medical records.

More than 6,500 women in the database gave birth in water, either at home or in a free-standing birthing center.

The outcomes in those births were compared to the outcomes for non-water births.

The study compared only births at home or in a birthing center and not those in hospitals.

The researchers found that babies born in water were no more likely to require transfer or admission to a hospital, nor were the mothers who gave birth in water. However, the researchers found an 11 percent increase in perineal tearing among mothers who gave birth in water.

“For some women, that potential risk of tearing might be worth taking if they feel they will benefit from other aspects of a water birth, such as improved pain management,” Bovbjerg said. “There is no one correct choice.

The risks and benefits of different birthing options should be weighed carefully by each individual.”

The researchers’ findings are congruent with outcomes reported in other water birth studies, Cheyney said, but are contrary to the American College of Obstetricians and Gynecologists’ and the American Academy of Pediatrics’ Committee Opinion.

“Those groups support laboring in water, but caution against giving birth while immersed,” Cheyney said. “Our findings suggest that water birth is a reasonably safe option for low-risk women, especially when the risks associated with pharmacologic pain management, like epidural anesthesia, are considered.”

The researchers have shared their findings with a group that is developing a clinical bulletin designed to inform health care providers about the practice of water birth in both hospital and out-of-hospital settings.

A comparison of water births and conventional vaginal deliveries

Otigbah CM; Dhanjal MK; Harmsworth G; and others, (July 2000).

European Journal of Obstetrics and Gynecology and Reproductive Biology , vol 91, no 1, July 2000, pp 15-20.

Setting, participants, design and aim:

The study took place in a district general hospital over a five year period, 1989-1994 and involved a total of 602 mothers. A retrospective case-control study which analysed data on 301 mothers who had a water birth and another 301 who had a normal land birth.

The aim was to explore the effects of water immersion on labour and birth, as compared with normal land birth.

Method: The study centre had several pool selection criteria which accepted women who were considered to be at low risk of complication for the pool.

They were required to have: * no medical or obstetric problem; * a gestation of at least 38 weeks with a normal sized fetus; * cephalic presentation; * clear liqour if membranes were already ruptured; * a reactive admission cardiotocograph.

The controls were selected from the unit’s audit data, as the next parity matched woman who was low risk, had a normal birth and did not have labour augmentation.

The variables compared and analysed included: * labour length; * analgesia uptake; * Apgar scores; * maternal complications – namely perineal trauma, postpartum haemorrhage and infection; * neonatal complications – namely shoulder dystocia, admission to special care baby unit (SCBU) and infection.

Data were analysed using the Chi-squared test to compare proportions, and Student’s t test to compare means. Any difference was considered significant if the P value was <0.05. Results: * Primigravidae who had a water birth had a significantly shorter first stage (P <0.05) and second stage (P <0.005) of labour.

The total labour length was 90 minutes shorter; * Water birth mothers, whatever their parity, used significantly less opioid pain relief, either alone or in addition to entonox – 1.3% compared to 54% of the controls (P <0.0001).

A total of 38% water birth women had no analgesia compared to 8% of the control group (P <0.0001); * Water birth mothers had significantly fewer episiotomies – 5%compared to 25% (P <0.0001), although they had more vaginal, 1° and 2° perineal tears overall – 53% versus 39% (P <0.001).

Water birth primigravidae had more intact perinea – 41% compared to 36%, although this was not statistically significant; * Fewer postpartum haemorrhages occurred among water birth mothers – 1.3% versus 2.7%; * One case of maternal pyrexia was reported on a multiparous water birth woman who was treated with antibiotics; she had no positive cultures on subsequent sampling; * No significant difference was reported between the groups in the mean Apgar scores at one and five minutes; *

Two water birth babies were admitted to SCBU with low Apgars.

In one case there was a true knot in the umbilical cord and the other followed a difficult delivery with an unexpected compound presentation; * Five babies in the water birth group and four in the control group had shoulder dystocia; * No neonatal infections were reported.

Abstract writer’s comments:

This is clearly an interesting and worthwhile study which includes data on a good size sample of mothers and babies.

A key strength is the analysis and presentation of the data by parity as often findings relating to primigravidae and multigravidae are amalgamated, despite the influence of parity on factors such as use of analgesia, labour length and type of delivery.

The authors acknowledge the limitations of a non-randomised water group sample.

It would have been interesting to have collected information relating to the social class of pool users, as there is an assumption among health professionals that birthing pools attract greater interest among middle class women, but I know of no evidence to support this view.

The researchers report a shorter labour for water birth primigravidae but do not mention the frequency of vaginal examinations, or whether the second stage was timed when the presenting part was visible, making the precise process of how they timed these labour stages unclear.

The effect of water immersion on analgesia uptake appears striking.

The authors suggest that an influencing factor may have been the continuous midwifery care, often by a known midwife, for pool users, as opposed to an intermittent midwifery presence by a midwife unknown to a mother before her labour.

There is, however, no mention whether any facilities such as beanbags, birthing balls, rocking chairs or floor mattresses were available to women who did not use the pool, apart from presumably a delivery bed.

It is therefore not known whether these women were encouraged to adopt comfortable positions and be as mobile as possible throughout labour.

The practice of maximising maternal mobility has been shown to reduce the perception of pain and thus the uptake of analgesia.

Whilst it is reassuring that fewer episiotomies were performed on water birth women, nonetheless, fifteen still had one!

It would be interesting to know something about the study centre’s approach to care during the second stage regarding pushing techniques and time perimeters, as this could have influenced the incidence of both tears and episiotomies.

The researchers note that ‘particular care was taken to ensure controlled delivery of the head’ (p16) but do not explain how, ie if the midwife touched the head and perineum or not.

Besides, tears often occur with the birth of the shoulders.

Comparison was made between the groups on the incidence of postpartum haemorrhage, but no mother appeared to have a completely physiological third stage because the cord was clamped and cut promptly after the birth, which disturbs the physiology, and the placentas were delivered out of the pool.

The rationale for leaving the pool was to estimate blood loss more accurately – a difficult thing to achieve in or out of water.

A second reason was the totally unproven risk of water embolism.

This study reported no adverse effect for mothers or babies associated with water immersion during labour and birth and forms a useful basis for future research.

Water birth: a review of 848 deliveries and a comparison with other delivery positions

Thoeni A; Holzner J, (2002). International Confederation of Midwives. Midwives and women working together for the family of the world: ICM proceedings CD-ROM Vienna 2002. The Hague: ICM , 2002. 7 pages.

Objective:

The object of our study was to analyze 848 consecutive water births and to compare them with two other delivery positions.

Methods:

We compared 848 water births, 493 deliveries in the traditional bed, and 172 deliveries on the delivery stool.

Duration of labor, rates of episiotomies and lacerations, arterial cord blood pH, base excess, analgesic requirements, and postpartum maternal haemoglobin levels were evaluated.

Results:

The first stage of labor was significantly reduced in primiparas with water birth compared with the other delivery positions (386 vs. 477 min., respectively).

There were no differences in the duration of the second stage (32 vs 39 min.).

The low episiotomy rate with the water births (1% compared with 18% and 8% for the other two positions) was not associated with an increased rate of perineal lacerations (23% in all three groups).

Of the primipara, 59% had no lacerations with water birth compared with 36% and 46% for the other two positions, respectively.

No woman with water birth required analgesics.

There were no differences among the groups in arterial cord blood pH or postpartal maternal haemoglobin level.

Conclusion:

Our results suggest that water birth is associated with a significantly shorter first stage of labor, lower episiotomy rate and perineal lacerations, and reduced analgesic requirements compared with other delivery positions.

Water birth is safe for the mother and fetus-neonate if candidates are selected appropriately.

Study confirms… Women who labour in water have lower rate of epidural analgesia

Randomised controlled trial of labouring in water compared with standard of augmentation for management of dystocia in first stage of labour

Objectives:

To evaluate the impact of labouring in water during first stage of labour on rates of epidural analgesia and operative delivery in nulliparous women with dystocia.

Design Randomised controlled trial.

Setting University teaching hospital in southern England.

Participants 99 nulliparous women with dystocia in active labour at low risk of complications.

Interventions Immersion in water or standard augmentation for dystocia (amniotomy and intravenous oxytocin).

Main outcome measures:

Primary: epidural analgesia and operative delivery rates.

Secondary: augmentation rates with amniotomy and oxytocin, length of labour, maternal and neonatal morbidity including infections, maternal pain score, and maternal satisfaction with care.

Results:

Women randomised to immersion in water had a lower rate of epidural analgesia than women allocated to augmentation (47% v 66%, relative risk 0.71 (95% confidence interval 0.49 to 1.01), number needed to treat for benefit (NNT) 5).

They showed no difference in rates of operative delivery (49% v 50%, 0.98 (0.65 to 1.47), NNT 98), but significantly fewer received augmentation (71% v 96%, 0.74 (0.59 to 0.88), NNT 4) or any form of obstetric intervention (amniotomy, oxytocin, epidural, or operative delivery) (80% v 98%, 0.81 (0.67 to 0.92), NNT 5).

Conclusions:

Labouring in water under midwifery care may be an option for slow progress in labour, reducing the need for obstetric intervention, and offering an alternative pain management strategy.

(Extract from abstract of Randomised controlled trial of labouring in water compared with standard of augmentation for management of dystocia in first stage of labour by Elizabeth R Cluett, Ruth M Pickering, Kathryn Getliffe, Nigel James, St George Saunders published in British Journal of Midwfery January 26, 2004)

Evidence on the safety of water birth

9 February 2015

Evidence Based Birth – Rebecca Dekker

In April 2014,  waterbirth—an alternative method for pain relief in which a mother gives birth in a tub of warm water—made national headlines.

The event that pushed water birth safetyinto the spotlight was a joint Opinion Statement from the American Congress of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics (AAP), denouncing the practice.

In their opinion statement, ACOG and the AAP firmly admonished that waterbirth should be considered an experimental practice that should only occur in the context of a clinical research study.

Their conclusion, which echoed a previous AAP Opinion Statement from 2005, was based on their opinion that water birth does not have any benefits and may pose dangers for the newborn.

In response, the American College of Nurse Midwives (ACNM),(Midwives 2014) the American Association of Birth Centers (AABC), and the Royal College of Midwives (RCM) all released statements endorsing waterbirth as a safe, evidence-based option.

Meanwhile, the AABC released preliminary data from nearly 4,000 waterbirths that occurred in birth centers all over the U.S., supporting water birth as safe for mothers and infants.

Despite the response from midwifery organizations and the AABC, hospitals all over the U.S. began suspending or shutting down their waterbirth programs.

At St. Elizabeth’s Regional Medical Center in Lincoln, Nebraska, mothers and families organized rallies and started a change.org petition to bring waterbirth back.

All of this controversy left us with these questions— Is the ACOG/AAP statement based on a complete and accurate review of the literature?

What is the evidence on waterbirth?

Is it safe?

Does it have any potential benefits or harms for mothers and infants?

These are the questions we will address in the Evidence Based Birth article on the evidence on waterbirth.

This article was published July 10, 2014, by Rebecca Dekker, PhD, RN, APRN
© Evidence Based Birth, All Rights Reserved.

Click here for a copy of Rebecca Dekker’s paper on the safety of water birth

Water VBAC: exploring a new frontier for women’s autonomy

McKenna JA; Symon AG, (2014). Midwifery , vol 30, no 1, January 2014, e20-5.

BACKGROUND: although Vaginal Birth After Caesarean section (VBAC) has been promoted successfully as one means of reducing the caesarean section rate, the practice of VBAC using water immersion (Water VBAC) is restricted.

Very little valid, reliable research evidence is available on this birth method, although initial small-scale audits indicate that Water VBAC has no adverse effect on maternal and neonatal outcomes.

METHOD: in-depth semi-structured interviews were carried out with a purposive sample of eight women who had undergone Water VBAC in one midwife-led unit.

The interviews aimed to explore their reasons for requesting this birthing method, and their experience of the process. An interpretative phenomenological analytical approach was adopted.

FINDINGS: the women pursued Water VBAC for two main reasons: in order to prevent a repeat of the obstetric events that previously led to a caesarean section, and to counteract their previous negative birth experiences.

The women reported improved physical and psychological outcomes from their Water VBAC experience when compared with their previous experience of caesarean section.

Three main themes emerged: ‘minimising’, ‘maximising’ and ‘managing’. Water VBAC entailed an attempt to minimise the medicalisation of the women’s childbirth experience.

This was achieved by limiting medical staff input in favour of midwife-led care, which was believed to minimise negative physical and psychological experiences.

Correspondingly, Water VBAC was perceived as maximising physical and psychological benefits, and as a means of allowing women to obtain choice and assert control over their labour and birth.

The women planning a Water VBAC believed they had to manage the potential risks associated with Water VBAC, as well as manage the expectations and behaviour of friends, family and the health care professionals involved in their care.

CONCLUSIONS: for the women participating in this research, actively pursuing Water VBAC constituted a means of asserting their autonomy over the childbirth process.

The value accorded to being able to exercise choice and control over their childbearing experience was high.

These women’s accounts indicated that information-giving and shared decision-making require improvement, and that inconsistencies in the attitudes of health care professionals need to be addressed.

 

The use of water immersion in the facilitation of ‘normal labour’

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.

Integrating Data from the New Waterbirth Study into Care

An Evidence-informed Practice Framework

A new study on the safety of waterbirth was released in the Journal of Midwifery & Women’s Health on January 20, 2016, authored by MANA Division of Research Coordinator Council members, Drs. Marit Bovbjerg, Melissa Cheyney, and Courtney Everson.

This study used data from the MANA Stats project (2004 to 2009) and reported on neonatal and maternal outcomes for 6,534 babies born underwater in home and birth center settings.

Using an evidence-informed practice (EIP) framework, this blog will help you understand the potential care implications of this research.

~Haven’t had a chance to read the study yet? Read it here first and then come back to this blog for additional guidance!~

What is evidence-informed practice (EIP)? Also referred to as “evidence-based practice,”  “evidence-based care” or “evidence-based medicine,” an EIP framework is the intersection between the best available research, your professional expertise as the practitioner, and the client’s individual values, needs, and context.

Figure 1 (below) visually depicts EIP. EIP helps improve client care, and supports informed choice and shared decision-making models. (For more information on the EIP framework and resources, see: News From the DOR: Implementing Evidence-Informed Practice During Midwifery Care, November 2015 Blog by C. Everson)

What is Evidence-Informed or Evidence-Based Practice (EIP/EBP)?

Figure 1: Evidence-informed practice

 

Let’s look at the outcomes of the new waterbirth study through the EIP lens:

Best available research evidence

Professional expertise

Client values and individual needs

Best Available Research Evidence

Let’s start with highlights from the research:

The study included data from 18,343 women who had home or birth center births; 6,521 (35%) of these women had waterbirths. The researchers found no evidence of harm to babies who were born underwater. Whether looking at 5-minute Apgar score, neonatal transfer to the hospital, any hospitalization in the first 6 weeks, NICU admission in the first 6 weeks, or neonatal death, the results were clear: babies born underwater fared as well as those babies whose mothers did not choose a waterbirth.

While the study confirmed that mothers who had a waterbirth were not at increased risk of postpartum transfer (for a maternal indication), hospitalization in the first 6 weeks, or perineal/uterine infection, the study did suggest that mothers who choose waterbirth have a slightly increased risk of experiencing perineal trauma.

This study is the largest ever published, and the first study to be published in a US population. It provides solid evidence that waterbirth can be a safe and viable option for many lower-risk pregnant women, though midwives and other health care professionals should, as with all childbearing decisions, discuss potential risks and benefits with families and engage in shared decision making.

One final important point from the research: there were actually THREE groups. Waterbirth, non-waterbirth, and intended-waterbirth. This latter group consisted of those women who had planned a waterbirth, but then did not have one. Women and neonates in this intended waterbirth group had the worst outcomes of the three groups in this study—more on them later. For now, what you need to know is the main conclusion from the study: waterbirth is not associated with ANY adverse outcome for the baby, but it might be associated with an increased risk of tearing for the mother.

Professional Expertise

Now, let’s consider the data from a clinical perspective:

This study demonstrates what midwives already know: waterbirth is safe for babies. The take home message: nothing in this study suggests that midwives need to change current practice to increase safety for neonates during waterbirth.

However, we want to apply our clinical expertise to dig deeper into the adverse finding of increased perineal trauma for some women. The data cannot tell us the full story because there are not enough variables to create a discernible pattern—or in other words, while the research suggests that there is an increase in perineal trauma among women who gave birth in the water, there was no pattern in terms of where or how bad the trauma was.

What we can do, however, is consider this question from a clinical perspective. Possible contributing factors include: How long was the woman in the water? Were “hands on” or “hands off” techniques used for perineal support and protection? Could the birth position (hands and knees, squatting, etc.) be a factor? Your experience as a midwife allows thoughtful reflection on why an increase may have occurred, and this forms the professional expertise area of an EIP approach.

You may also be questioning why outcomes were worse for the intended-waterbirth group, compared to the waterbirth and non-waterbirth groups. From your clinical experience, you may have come to this logical conclusion: if complications arose during labor, the midwife may have requested that the client get out of the tub in order to facilitate closer monitoring. This may mean that midwives are engaging in appropriate screening to ensure that clients remain good candidates for a waterbirth (of course, some women also just choose to get out of the tub on their own accord).

On the flip side, you may have noticed that the best outcomes were among the waterbirth group. Does that mean that waterbirth is actually beneficial? Not necessarily. What we have to remember is that “best” and “worst” is relative to the other groups involved. In other words, the outcomes of babies born under water were better compared to those babies not born under water.

Why would the outcomes for waterbirth babies be better, comparatively? One explanation is that the lowest risk women stayed in the water, just like the higher risk women may have been asked to get out of the water. What this means is that the location of birth (waterbirth, intended-waterbirth, non-waterbirth) may be serving as a proxy for the risk level of the mother.

In research, we call this “selection bias.” Recognizing this bias helps us to understand why even though it may look like waterbirth is beneficial (because those babies have the best outcomes), the improved outcomes are likely a reflection of who stayed in the water and who did not.

While selection bias may mean that waterbirth by itself does not improve outcomes, it also does not take away from the key finding: waterbirth is safe for babies. We can say this with certainty because all 6,534 neonates in the waterbirth group were, in fact, born underwater, and there was no evidence of increased risk for any outcome.

Client Values & Individual Needs

Finally, let’s integrate our clients’ values and individual needs:

Midwives provide informed consent on the risks and benefits of waterbirth using a shared decision-making framework. You counsel clients using what you know from research and your own practice, and the family then decides what route is best for them and their baby.

The new understanding of increased risk of perineal trauma will need to be discussed. Other key findings that demonstrate the safety of waterbirth should also be shared, such as: 1) there was no increased risk of mortality or morbidity for newborns; and 2) that waterbirth was not associated with maternal hospitalization in the immediate or first six weeks postpartum, or with maternal infection.

By engaging shared decision-making and EIP frameworks, you can (and should) also draw on the larger body of literature on waterbirth (see the references list in the current study to get you started) as well as professional practice guidelines, including a soon-to-be-released evidence-based waterbirth clinical bulletin drafted by a multi-stakeholder group (anticipated release: Spring 2016).

Collectively, existing research combined with your expertise as a midwife allows you to engage in a detailed and comprehensive conversation with clients, where autonomy in decision-making can be exercised within an EIP framework.

Concluding Thoughts

Excited about this research? We are too, and we owe it all to you! This research would not be possible without the many midwives who contribute data to the MANA Statistics project.

The ability to even study waterbirth highlights the value of the MANA Stats project, which provides a rich dataset focused on physiologic birth practices. Without this data source, large research studies on practices like waterbirth would be difficult, given their relative infrequency in the hospital.

So, midwife contributors, many thanks for taking the time to advance research on midwifery care and physiologic birth practices! And for those midwives not yet contributing, you can sign-up anytime! Learn more, here.

About the authors

Courtney Everson

Courtney L. Everson MA, PhD is a Medical Anthropologist and the Dean of Graduate Studies at the Midwives College of Utah, Salt Lake City, UT. Dr. Everson is also the Director of Research Education for the Midwives Alliance of North America (MANA) Division of Research (DOR); Co-founder and Vice President of the Oregon Doula Association (ODA); a Research Working Group (RWG) member of the Academic Collaborative for Integrative Health (ACIH); an Accreditation Review Committee (ARC) member for the Midwifery Education Accreditation Council (MEAC); and serves on the Boards of Directors for the Australasian Professional Doula Regulatory Association (APDRA), the Oregon Doula Connection, the Association of Midwifery Educators (AME), and the Academic Collaborative for Integrative Health (ACIH). Dr. Everson’s research and teaching specializations include: maternal-child health; human childbirth; adolescent pregnancy and parenting; psychosocial stress; social support; doula care; midwifery care; research and clinical ethics; evidence-informed practice; collaborative care models; mixed methodologies; health inequities; cultural competency/humility; social justice; and underserved populations. She actively publishes in academic forums, and is an invited, avid speaker at local, national and international venues.

Marit Bovbjerg

Marit Bovbjerg PhD, MS is a reproductive and health services epidemiologist at Oregon State University. Dr. Bovbjerg’s research focuses on maternity care in the US, with a sideline into physical activity during pregnancy/postpartum. In her non-work time, she likes to knit, grow vegetables, cook, and play outside (hiking, running, biking, etc.) She does not like to sit still and in fact avoids doing so whenever possible. Marit and her husband are attempting to turn three exuberant children into responsible adults, a task at which they might, on a good day, be slowly succeeding (though likely through no fault of their own). They live in an untidy but cheerfully-painted house in rural Oregon, and enjoy vacationing in places with abundant outdoor activities but few people.

Missy Cheney

Melissa Cheyney PhD, CPM, LDM is Associate Professor of Clinical Medical Anthropology at Oregon State University (OSU) with additional appointments in Public Health and Women’s Studies. She is also a Certified Professional Midwife in active practice, and the Chair of the Division of Research for the Midwives Alliance of North America where she directs the MANA Statistics Project. She is the author of an ethnography entitled Born at Home (2010, Wadsworth Press) along with several, peer-reviewed articles that examine the cultural beliefs and clinical outcomes associated with midwife-led birth at home. Dr. Cheyney is an award-winning teacher and was recently given Oregon State University’s prestigious Scholarship Impact Award for her work in the International Reproductive Health Laboratory and with the MANA Statistics Project. She is the mother of a daughter born at home on International Day of the Midwife in 2009.

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Immersion in water in labour and birth | Cochrane Summaries 2012

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.

Laboring in water helpful for dystocia

Originally published by Laurie Barclay, MD 
Medscape Medical News. 
Jan. 26, 2004

Laboring in water can be helpful in dystocia, according to the results of a randomized controlled trial published online Jan. 26 in the British Medical Journal.

“Incomplete understanding of labour may lead to unnecessarily early intervention,” write Elizabeth R. Cluett, from the University of Southampton in the U.K., and colleagues.

“Labouring in water under midwifery care may be an option for slow progress in labour, reducing the need for obstetric intervention, and offering an alternative pain management strategy.”

To test their hypothesis that laboring in water can relieve pain and anxiety and thereby reduce the need for interventions, the authors compared outcomes for immersion in water in a birth pool during the first stage of labor with those for standard augmentation including amniotomy and intravenous oxytocin.

Subjects were 99 nulliparous women with low risk of complications and with dystocia, defined as cervical dilation rate less than 1 cm/hour in active labor. Primary outcome measures were rates of epidural analgesia and operative delivery.

Compared with women receiving standard care, those receiving water immersion had a lower rate of epidural analgesia (47% vs. 66%; relative risk [RR], 0.71; 95% confidence interval [CI], 0.49 – 1.01), number needed to treat [NNT] for benefit = 5).

Rates of operative delivery (49% vs. 50%; RR, 0.98; 95% CI, 0.65 – 1.47; NNT = 9 and overall labor length were similar in both groups.

However, significantly fewer women in the water immersion group received augmentation (71% vs. 96%; RR, 0.74; 95% CI, 0.59 – 0.88; NNT = 4) or any obstetric interventions including amniotomy, oxytocin, epidural, or operative delivery (80% vs. 98%; RR, 0.81; 95% CI, 0.67 – 0.92; NNT = 5).

Women in the water immersion group also reported significantly lower pain scores and higher satisfaction with freedom of movement than did women in the standard care group.

Although more newborns in the water group were admitted to the neonatal unit (6 vs. 0; P = .013), there was no difference between groups in Apgar score, infection rates, or umbilical cord pH.

Limitations of this study include recruitment of only 99 of 220 eligible women, increased difficulty with recruitment toward the end of the trial because of changes in standard care, and sample size too small to detect statistical differences in use of epidural analgesia.

“Delaying augmentation in association with a supportive environment (water immersion) is acceptable to women with dystocia and may reduce the need for epidural analgesia without increasing labor length or operative deliveries,” the authors write.

“A management approach that reduces rates of augmentation and associated obstetric intervention may contribute positively to maternal physiological and psychological health: oxytocin infusion is known to increase the risk of uterine hyperstimulation and fetal hypoxia, and obstetric interventions are associated with lower maternal satisfaction.”

The authors report no financial conflicts of interest. BMJ. Published online Jan. 26, 2004. Reviewed by Gary D. Vogin, MD

BMC Pregnancy and childbirth – Immersion in water for pain relief – 2014

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

 

Exploring breech water birth

Maggie Banks – RM, PhD, ADN, RGON

The paucity of literature on labour and birth in water with breech- presenting babies highlights a need to share (and document) empirical knowledge on the subject to piece together women’s and midwives’ growing experiences.

I was asked recently if leaving a woman in a birth pool to give birth to a breech presenting baby, undiagnosed until on the perineum, was ‘reasonable’ midwifery practice.

The question was qualified in that if the breech baby had been known prior to labour, the birth would definitely not have occurred in water as it is contraindicated in all the waterbirth guidelines in New Zealand.

My initial reaction, though fleeting, was to shrink away and not own my own experiences, knowing that these would be viewed as ‘unreasonable’ given that guidelines were presented as a self-evident truth that could not be argued with, that is, a known breech baby would not be born in water.

The issue of breech presentation and waterbirth is one that I have repeatedly explored in the midwifery and obstetric literature over the years and have found little written on the subject.

What is there usually cites the same source – Herman Ponette, the Belgium obstetrician in Ostend who actively promotes waterbirth with breech babies.1 There is minimal acknowledgement that it occurs in hospitals in the USA and the UK.2, 3

A Google search using the term ‘breech waterbirth’ brings up a handful of consumer stories and the occasional midwifery website which discusses the issue. Of the numerous stories I receive from women and midwives about breech birth, increasingly they involve the use of water.

This article pieces together some knowledge gained from reading, discussions, several of my experiences of, and reflections on, the use of water immersion with breech babies.

Going with the Flow

Initially I had been mindful of Michel Odent’s recommendation of not using deep warm water during breech labour as he warns that the soothing effect of water may mask an unduly painful labour, thereby preventing early detection of what may prove to be a problematic birth.4

My own first experience of using water in a breech labour happened by accident in that the frank breech baby remained undiagnosed until on the perineum. The woman had used the pool unconventionally in labour – she chose to lounge in the pool between contractions and stood during them. Once the breech was diagnosed I asked her to leave the pool and she stood to give birth.

This made me re-look at Michel’s caution. My experience of waterbirth with cephalic presentation had shown me that water immersion only mellows out normal labour pain, not severe or pathological pain, which would indicate the bone on bone painof true disproportion between pelvis and presenting part.

I had to question why this should be any different for a breech presenting baby – and I could not find an answer.

With the same woman’s second frank breech baby, this time diagnosed in pregnancy, she again used the pool unconventionally to relax between her contractions, and she birthed standing on dry land.

These two experiences marked a small shift in the use of water during my attendance at breech labour and birth in that water immersion remained available with a known breech. However, I continued to arrange with women that they would leave the pool for birthing.

This request changed following the birth of Heath, a firstborn presenting as a flexed legs breech. His mother had been deeply relaxed in the pool, assuming a wide open kneeling position leaning over the edge of the pool.

When the baby was visible on the perineum and the urge to push was overwhelming I asked the woman to leave the pool as we had prearranged, which she did.

Whereas she had been strong, independently held her own weight, and was powerful in her pushing, once out of the pool, she needed physical support to be in active birth positions and was unable to relax deeply between contractions as she had previously done in the pool.

The baby was born within half an hour of pushing and all was well but it was clear to me that I had intervened in a physiological birth and this had altered the ease with which the woman gave birth.

This birth occurred some months after the 1st International Waterbirth Conference in 1995.

Publication of Paul Johnson’s classic article 5 on the mechanisms that prevent or, conversely, stimulate breathing in the unborn baby during waterbirth would occur the following year but, in concluding his conference write up, Johnson, a Consultant Clinical Physiologist in the O&G Department at the John Radcliffe Hospital in Oxford, wrote:

“…if the onset of labour is spontaneous, and no drugs are administered, a fetus born with its cord intact, into warm, fresh water, not asphyxiated, is inhibited from breathing”6 – a process not dependant on presentation.

Initiation of breathing following waterbirth occurs once the baby surfaces and is exposed to cooler, dryer air and clamping the umbilical cord 6 – again, irrespective of presentation.

Sheila Kitzinger would report his additional comment that “if water births are of psychological and physiological benefit, it is logical that this benefit should apply to high-risk women too”.7

I knew deep water immersion to be a very powerful modality for achieving a relaxed state for the woman, enhancing vasodilation and placental perfusion and, therefore, oxygenation, of the tissues and organs, including the placenta during the normally stressing (not distressing) time of labour.

I had seen women become oblivious to everyone and everything as they sank into the pool. I had come to recognise the depth of sigh on entering the pool that signalled release of pain, fear, social etiquette and conversation – and these observations were irrespective of whether the baby was coming head or bottom first.

The Buoyancy and Warmth of Water

Another dimension was added when I attended a woman with twins, the second baby being a breech presentation. The woman had grown her babies well and began labour spontaneously at 40 weeks.

Due to the heaviness of her abdomen, she was drawn to labouring in water – her bath at home then, when labour was well established and she had travelled to her chosen birth place, the spa bath in the obstetric hospital.

There was a point in her labour where she needed to be more upright than reclining in the spa bath allowed, so we set up my free standing birth pool for her.

With the water up to the level of her breasts she became almost weightless in the pool, and was able to assume her intuitive positioning in a deep squat for the births of both her babies, the second of which had remained breech.

The woman reflected how supportive the water had been and how the upright position engaged her strength and ability to birth well.

Controlling Pelvic Pressure

When vaginal breech birth was a common occurrence 15 years or so ago, epidural anaesthesia was commonly recommended to overcome a premature urge to push. However, discussion with midwifery colleagues indicates a premature urge to push with a term breech baby is rare in woman-controlled positioning.

One woman who did experience significant pelvic pressure from the onset of labour with spontaneous rupture of membranes while having her first baby – a frank breech presentation – provided a piece to the mosaic of the use of water.

She controlled the urge to push by long and slow breathes during contractions and lying on her side on a floor mattress for most of her labour, rising only to crawl to the toilet on her hands and knees. After 12 hours of this, the pressure was overwhelming, even when lying.

While her good progress was evident from the lengthening burgundy buttock crease and her birthing energy, it was not time to use that expulsive energy. A vaginal examination confirmed a thin rim of cervix remained.

While a hands and knees position reduced the pressure, it was not until she lounged in the pool on her abdomen that the pressure again became tolerable. The pool was invaluable for enabling her to resume breathing over the contractions for the next three hours.

In the last hour prior to the birth, the woman commenced her grunting expulsions. As this had not brought her baby to a visible position in that time, I asked her to stand for one contraction to test the power of this feeling.

Simply standing engaged the pelvic pressure enough to bring the baby to almost rumping with the first push.

The second surge saw the baby rumped and progress so the popliteal spaces (back of the knees) were visible. With the next, he was born to the ankles, then descended quickly to wear his ‘perineal hat’ and his head was gently released without perineal trauma. All of this occurred without a contraction as the women responded to the pelvic pressure.

Assessing the Baby

The New Zealand Guideline Group’s best practice evidence-based guideline on breech labour and birth acknowledges that the evidence does not support continuous electronic foetal heart rate (EFM) monitoring by cardiotocography over intermittent auscultation.8

This is because, just as for well women and their babies with no alerting factors, there are no significant differences in standard measures of newborn wellbeing (including cerebral palsy and infant mortality) with continuous EFM in labour for ‘high risk’ situations, which frank or flexed legs breech presentation at term is deemed to be by some.

Only beneficial for its association with a reduced incidence of neonatal seizures, continuous EFM is associated with increased maternal morbidity by way of the accompanying increase in Caesarean and operative birth rates.9

At any given point the midwife needs to know that the baby is coping well with labour by assessment of his movements10 and listening to his heart beat.

As with any other labour for well women and babies, listening can be easily acheived with a Pinard stethoscope (or handheld, waterproof doppler) during water immersion.

Essential Elements of Physiological Breech Birth

Midwives commonly reflect on how their practice changes with attending waterbirths of cephalic presenting babies to become more ‘hands-off ’ during birth.

Confident that the water frequently dissipates urges to explosively push, while also supporting the woman’s perineal tissues and the baby as he is born, the midwife is drawn to a non touch vigilant attendance. This ‘hands off ’ in the absence of problems is the ‘golden rule’ during breech birth.

Maternal effort is an important part of achieving a ‘hands-off ’, spontaneous birth. As with any birthing, the woman needs to be supported to choose positions of comfort in the water which enhance her power and strength – kneeling, squatting, hands and knees or reclining.

Whichever birth position is chosen, the midwife needs to position herself so she can see both the advancing baby and the umbilical cord, and be in a position to palpate the umbilical cord if necessary.

The midwife may need ‘hands on’ for the birth of the head but the support of the water usually ensures gentle and woman- controlled birth of the baby’s head. Due to the reduction in gravity and an accompanying reduction in an urge to push for the head, the woman may need to be reminded to release the baby’s head.

Midwives who regularly attend waterbirths with cephalic presentation frequently reflect that if there is a problem during birth, for example, shoulder dystocia, they will initially try to correct it in the pool.

This avoids delay while utilising the water’s buoyancy so the woman can move easily to adopt very wide open positions that are needed for manoeuvres.

While Pinotte1 notes a reduced need for routine manipulations of the breech baby with waterbirth, in the rare circumstance that a manoeuvre is needed – to bring down stuck arms11 and/or flex, cradle and scoop out the baby’s head12 – these could also initially be done in the pool, again, avoiding delay.

The woman, however, would be asked to get out of the pool if problems were not easily remedied.

The Ongoing Mosaic

For some maternity professionals the issue of vaginal breech birth is no longer worth considering in the wake of the Term Breech Trial13 despite concerns about its methodological flaws.14-17

For others it remains a planned option.18-22 There will, of course, always be undiagnosed breech babies in labour, irrespective of the degree of antenatal scrutiny.

While some consider undiagnosed breech an ‘obstetric emergency’, the manner in which a midwife facilitates
a vaginal breech birth, first diagnosed when birth is imminent, is the sameas if it was diagnosed antenatally and a vaginal breech birth is planned, albeit the latter having obstetric backup available with the birth in an obstetric hospital.

The use of deep water immersion with mal-presentation (read: breech)
is contraindicated in hospital clinical guidelines on waterbirth, and the use of water is absent as a modality in vaginal breech birth guidelines.

Embracing these, giving birth in water to a breech baby would be out of the question for some maternity providers.

Yet others are very specific
 in seeing breech presentation as a positive indication for waterbirth because of the buoyancy afforded to the baby and umbilical cord, both of which are kept warm in the water until surfacing into the cooler air,1,23,24 contraindicated only if the breech labour is not progressive and/
or is complicated.25

Midwifery can have additional knowledge fragments to obstetric knowledge, gained by our deep relationships with women.

Being attentive to women who are called to use water through breech labour and birth and walking side by side with them during this time has added to my understanding of facilitating physiological breech birth.

We need to be able to share the practice wisdom which comes from our experiences, discussions and reflections. We also need to be able to do this without fear of repercussions that may be activated from that disclosure. As a result, we will continue to find ongoing pieces to the mosaic of breech waterbirth.

References:

Ponette H. Breech and twin deliveries in the water. Accessed 20 March 2000. Available at http://www.helsinki. fi/~lauhakan/whale/waterbaby/p6.html
Kitzinger S. Sheila Kitzinger’s letter from England. Birth 1991;18(3):170–171.
Harper B. Waterbirth basics – from newborn breathing to hospital protocols. Midwifery Today 2000;54:9– 10,12–15,68.
Odent M. Birth reborn. Souvenir Press: New York, 1984:103–105.
Johnson P. Birth under water – to breathe or not to breathe. BJOG: An International Journal of Obstetrics and Gynaecology 1996;103(3):202–208.
Johnson P. Birth under water – to breathe or not to breathe. In, Lawrence Beech BA (ed).Water birth unplugged. Proceedings of the First International Water Birth Conference. Books for Midwives: Cheshire, England, 1996:31–33.
Kitzinger S. Sheila Kitzinger’s letter from England: is water birth dangerous? Birth 1995; 22(3):172–173.
New Zealand Guidelines Group. Care of women with breech presentation or previous Caesarean birth. New Zealand Guidelines Group: Wellington, 2004:xxi, 32.
Alfirevic Z, Devane D, Gyte GML. Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour. Cochrane Database of Systematic Reviews 2006, Issue 3. Art. No.: CD006066. DOI: 10.1002/14651858. CD006066.
Banks M. Utilising the unborn baby’s in-labour movements. New Zealand College of Midwives Journal 2003;29:6.
Banks M. Breech birth woman-wise. Birthspirit: Hamilton, New Zealand, 1998:88–89.
Ibid., pp. 90–91.
Hannah M, Hannah WJ, Hewson SA, Hodnett ED, Saigal S, et al. Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicenter trial. Lancet 2000;356:1375–1383.
Glezerman M. Five years to the term breech trial: the rise and fall of a randomized controlled trial. American Journal of Obstetrics and Gynecology 2006;194(1):20–25.
Kotaska A. In the literature: combating coercion: breech birth, parturient choice, and the evolution of evidence-based maternity care. Birth 2007;34(2):176–180.
Keirse MJNC. Evidence-based childbirth only for breech babies? Birth 2002;29(1):55–59.
Goer H. When research is flawed: planned vaginal birth versus elective Cesarean for breech presentation. Accessed 14 August 2007. Available at http://www.lamaze.org/ Research/WhenResearchisFlawed/ VaginalBreechBirth/tabid/167/ Default.aspx
Goffinet F, Carayol M, Foidart J, Alexander S, Uzan S, et al. Is planned vaginal delivery for breech presentation at term still an option? Results of an observational prospective survey in France and Belgium. American Journal of Obstetrics and Gynecology 2006;194(4):1002–1011.
Hellsten C, Lindqvist PG, Olofsson P. Vaginal breech delivery: is it still an option? European Journal of Obstetrics & Gynecology and Reproductive Biology 2003;111(2):122–128.
Sibony O, Luton D, Oury J, Blot P. Six hundred and ten breech versus 12,405 cephalic deliveries at term: is there any difference in the neonatal outcome? European Journal of Obstetrics & Gynecology and Reproductive Biology 2003;107(2):140–144.
Giuliani A, Schöll WMJ, Basver A, Tamussino KF. Mode of delivery and outcome of 699 term singleton breech deliveries at a single centre. American Journal of Obstetrics and Gynecology 2002;187(6):1694–1698.
van Roosmalen J, Rosendaal F. There is still room for disagreement about vaginal delivery of breech infants at term. BJOG: An International Journal of Obstetrics and Gynaecology 2002;109(9):967–969.
Charkowsky I. In: Napierala S. Water birth: a midwife’s perspective. Bergin & Garvey: London, 1994:181–182.
Enning C. Personal communication, 2008.
Ponette H. The New Aquatic Maternity in Ostend. Accessed 20 March 2000. Available at http://www.helsinki. fi/~lauhakan/whale/waterbaby/p2.html

Water birth and newborn GBS disease

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.

Aspects of the humanisation of water birth

23 October 2015: Yesie Aprillia S.Si.T, M.Ke

Originally published 31 January 2011

In the development of modern obstetrics the most important thing to be performed is the humanization of the labor and birth process.

This is an approach focused on the family, patient autonomy and pain management. This effort is essential for fetal and neonate safety.

The Royal College of Gynecologist and Obstetricians published guidelines, protocols were agreed upon, to prevent complications that are not predictable.2, 3

Thus guidelines are absolutely needed by the service provider of water birth. Guidelines or protocols are a main reference when formulating a basic approach to the patient and her family.

Some of the existing research indicates that being in the water during labor and childbirth provides a significant advantage in birth outcomes.

Each maternity unit should have a policy of water birth, including guidelines for patient preparation including information about water birth.

Service providers should be required to provide guidance on the process of childbirth to mother and family.2, 3,4,5,6

Understanding the risk factors that will be experienced by the mother and the baby is important, so that the prospective mother is completely ready to do the water birth.

Labor protocol is a matter that absolutely must be upheld to prevent risks and complications during labor.6

Considering risk for the baby is important.

However, the majority of medical experts believe that this situation is very rare, because babies will not breathe until the baby is exposed to air.7, 8

In 1999, Gilbert, et al published their research in 1996 by taking a sample of 4032 infants born in the water.

This study concluded that the prenatal mortality is not significantly higher than the risk of conventional childbirth.9

In the protocol designed for water birth, the Australian Government also asserts that all health workers involved are responsible for any information given to women candidates in each provider’s water birth techniques.

Data, which is provided, should be accurate and up to date .10 Patients have many birth choices to consider making informed consent important when choosing water birth. 7,8,9

In general, preparing the mother for waterbirth does not differ much than preparing the mother for conventional birth.

A conducive environment for the prospective mother during water birth strongly supports the success of this program. The role of the assisting family is important as well in the preparation of childbirth. 11

Patient Selection

Water birth is generally given to the term pregnant woman with no complications.10, 12

Confinement terms for water birth:

  1. Low-risk pregnancy
  2. No vaginal, urine, or skin infection
  3. Vital sign within normal limits and infants CTG normal (baseline, variability, acceleration)
  4. Warm water is used for relaxation and pain management after cervix dilatation of 4-5 cm or more.
  5. Patients cooperative with birth attendant instruction, including a possible exit from the pool if necessary.

Criteria / Indications 10, 13.14

  1. It is a mother’s choice
  2. Normal pregnancy > / 37 weeks
  3. Single fetus with head presentation
  4. No use of drugs-sedative
  5. Spontaneous broken membranes < 24 hours
  6. Non-clinical criteria such as staff and equipment
  7. No pregnancy complications such as pre-eclampsia, uncontrolled blood sugar level, etc.
  8. Normal heart rate
  9. Clear amniotic fluid
  10. Spontaneous childbirthing or after using misoprostol or pitocin
  11. There is no bleeding. It is difficult to assess the loss of blood in water birth due to the lack of attendant experience in water birth. If that be the case, some service providers may prefer to deliver the placenta outside of the pool.

Contraindications 10,13,16

  1. Infection that can be transmitted through the skin and blood.
  2. Febrile mother or other evidence of infection.
  3. Herpes genitalis. Herpes is very easily transmitted through water.
  4. Abnormal fetal heartbeat.
  5. Abnormal vaginal bleeding.
  6. HIV, Hepatitis.
  7. Macrosomia.
  8. Meconium. A light or medium meconium can be said normal in childbirth. However if thick meconium appears in the water, the attendant should clear or help the patient out from water birth pool.
  9. Breech presentation of the baby.
  10. Multiple pregnancy.
  11. Babies who are estimated to be born premature (2 weeks more or before the time of confinement)
  12. Condition that needs continual monitoring unless there is a condition where the waterproof transducers (Doppler) are available.

Technical Aspects

Provision facilities and infrastructure of water birth in general can be adjusted with the place where water birth will be implemented.

Clinics, hospitals and even at home can also be good settings for water birth as long as criteria is still met and the rules and guidelines are followed.

Based on the above, the technical procurement of water birth that must be owned: 16

Technical procurements on hand:

  1. Confinement pool
  2. Water pump: electric water pump works more quickly than hand water pump
  3. Water pipe: choose a quite long water pipe in order to reach water sources and confinement pool.
  4. Faucet hose adapter: choose the adapter that is easily removed and not part of other circuits.

Other suggested equipment:

  1. Debris removal Net. It is normal for the mother to defecate during second stage of labor, in this case, use debris removal net to retrieve and dispose of it.
  2. “Y” pipe adapter and End Cap to connect between Faucet adapter and water pipe.
  3. Hand-held Mirror. Many women in labor who start to push in hands and knees position. This position makes the mother unable to see the baby when the baby is born. By placing the mirror at the bottom of the foot and the light to the mirror, the mother can see the birth process easily.
  4. The lamp can be placed in the water directed to the mirror at the top so that the mother can see the birth process easily
  5. Thermometer in the water. This device helps care providers to regulate water temperature.
  6. Submersible water sucker. Portable sucker pipe means that pipes can be used to drain the pond without the need to find a power source.
  7. Gloves of sufficient length to protect care providers while listening to the heart of the baby or checking dilatation.

In addition to standard equipment, some equipment below should also available in the water birth service: 12

  1. Maternal thermometer.
  2. Waterproof Doppler.
  3. Water resistance cloth.
  4. Additional that can help the mother out of the pool if necessary.
  5. Knee bolster, cushion, low stool and birthing balls should preferably be provided so that care providers are comfortable (Burn & Kitsinger 2001).

In 1995, Alderdice et al., conducted research on 4494 retrospective confinement in the water made by midwives in England and Wales. They reported the deaths of 12 infants, 51 cases of illness (respiratory infection).

However, the researchers concluded that no evidence found that confinement in the water is less safe than conventional labor 20 American Academy of Pediatrics 19 mentions that the safety and effectiveness of the baby in water birth cannot be confirmed.

Meanwhile, the British Pediatric Surveillance8 mention deaths or the need for special handling of babies born in water from years 1994-1996.

Some reports of cases21 mention that there were sepsis of the baby because of pool contamination, but the numbers cannot be proven scientifically. Based on that, the procedure to maintain pool water cleanliness needs more attention by each provider of water birth.

Below are the procedures and guidelines quoted from the Australian government for the water birth: 12.

  1. Clean portable swimming pools with disposable liners
  2. In the practice of swimming pools, spa regimens should use solvents in jets, sucker pipes, pipes and filters. Between births the tub must be cleaned by using liquid Chlorine each time it is used.
  3. Cleaning fluid is a liquid that is commonly used in hospitals or who has received approval by the local organization.
  4. Birth tubs should be dried under the air.
  5. Birth tubs before re-use should be cleaned again.
  6. Reinforced with routine maintenance.
  7. Routine testing is done for Legionella in hospital water supply where the test bacteria is adjusted to the recommendations of local government.

Controversy about water birth has been around since 1723. It cannot be not separated from the various research results that have been conducted by various researchers in various countries.

In fact this method is widespread and popular in the community. Use of analgesia during labor is low and comfort earned by the mother during childbirth is a strong attraction for the candidates and the water birth services.

Quality improvement and standardization of services in accordance with guidelines is the key to comfort and safety of this technique. Therefore, researchers should continue to seek accurate information so that hey may develop reasonable guidelines for water birth. Valid research, of course, is supported by good research methods and controls.

Hopefully in the future with the increasing number of randomized and controlled trials we will be able to improve the scientific assessment of water birth. In summary water birth can be one of the best methods of childbirth sought after by expecting family’s aiming for baby’s gentle landing on earth.

References

  1. Grunebaum A, Chervenak Fa. In the baby or the bathwater: which one should be discarded?J. Perinatat.Med 2004; 32:306-7
  2. Alfirevic,Z,et al. Immersion in water during labour and birth (Royal college of obstetricians and gynaecologist/Royal college of midwives joint statement no.1).2006;{5 screen}.. Available from: URL: http:/ www.rcm.org.uk/info/docs/RCOG_RCM_Birth Accessed: May 12,2009
  3. Duley, L.M.M. Birth in Water (RCOG Statement no.1).2001:{3 screens}. Available from: URL: http://www.birthbalance.com/stories/serenity.pdf
  4. Palmer, J. In water during labour and birth. 2001; {4 screens}. Available from: URL: http://www.mybirthdesign.com
  5. Chapman,B. Water birth protocol: Five North Island hospital in NeW Zealand. College of midwives Journal.2004; 30:20-4
  6. Singh U, Schereiner A, Macdermott R, Johnston D, Seymour J, Garland D,et al.Guidelines for Water Birth within the midwifery led unit and at home (Dartford and Gravesham-NHS Trust).2006;{4 screen}. Available from: http//www.darentvalley hospital.nhs.uk . Accessed: May 13,2009
  7. Parker PC, Boles RG. In pseudomonas otitis media and bacterimia following a water birth. Pediatrics 1997; 99:653-4
  8. True about water risk and complications. 2006; {2 screen}. Availabel from: http://www.water birth risk often involve various problems with breathing.htm
  9. Gilbert,RE, Tookey, P.A. In Perinatal mortality and morbidity among babies delivered in water: surveillance study and postal
  10. Garland,D, Choo,YP, and birth –The royal college of midwives.2000;{4 screens}. Available from:URL: http://www.rcm.org.uk/info/docs/RCOG_RCM_Birth . Accesed: May 14,2009
  11. M (Ref not provided – ed. Active Birthpools)
  12. Policy-First stage labour in water. Government of South Australia.2005;{9 screens}. Available from: http://www.health.sa.gov.au/ppg/portals/0/waterbirth_First_Stage_Labour_in_Water_Policy_December_2005.pdf . Accesed: May 14,2009
  13. Guidelines for water at OHSU. Oregon health and sciences university water birth guidelines.2001;{1 screen}. Available from: URL: http://www.data.memberclicks.com/site/wi/OHSU_2001-guidelines.pdf .
  14. Water birth – Wikipedia, the free encyclopedia (Wikipedia foundation,, INC). 2007; {8 screens}. Available from: URL: http:/ www.enwikipedia.org/wiki/water_birth . Accessed: May 14,2009
  15. Anonymus. Waterbirth guidelines.2009;{1 screen}. Available at: URL: http://www.yourwater birth.com/water-birth-pools-liners-c-1.html.
  16. Roberts D. In guidelines for the use of water during labour and in the event of deliveries. Liverpool womens hospital NHS trust. 2002;{4 screen}. Available at:URL: http://www . Accessed: May 14,2009
  17. Burns E, Kitzinger S. Midwifery guidelines for use of water in labour. Oxford Centre for Health Care Research and Development, Oxford Brookes University, 2001
  18. Garland D. Waterbirth-an attidute to care. Cheshire: Books for Midwives,1995
  19. Batton, DG,et al. Underwater births. Pediatrics,2005; 115;5:1413-14
  20. Alderdice F, Renfrew M, Marchant S,et al. Labour and birth in water in England and Wales. BMJ 1995;310:837
  21. Vochem M, Vogt M, Daring G. Sepsis in a newborn due to pseudomonas aeruginosa from contaminated tub bath. BMJ 2001;345:378

MIDIRS: The use of water during childbirth

20 November 2015:

Since the early 1980s use of immersion in water during labour and birth has been increasingly promoted to enable women to relax, help them cope with pain, and maximise their feelings of control and satisfaction1-4.

In 1992 the House of Commons Health Committee recommended all hospitals provide the option of a birthing pool where practicable5. Currently few women give birth in water but the option of immersion or showering during the first stage of labour is commonly available.6-8

Although problems have arise which have been attributed to water use, the results of the most formal evaluations have not clearly associated water use with harmful outcomes for mother or baby 3,9-13.

The lack of robust evidence of harm or benefit means that childbearing women and health practitioners alike are subject to conflicting opinion about the usefulness and safest of water, particularly for birth.

However, a recent observational study over a nine year period concluded that ‘waterbirth was associated with low risks where obstetric guidelines were followed’16.

At present in the UK there is no reliable measurement of the rate of birth in water.
A national survey of maternity units in the UK in 2002 found that 63% (216/342) had a birthing pool8; 67% (228/342) reported having at least one midwife trained to provide support for women giving birth in water and 36% (121/342) said that at least half of the midwives working in their unit were trained to support birth in water.

How is water used during labour?

Water use ranges from informal, for example when a woman in early labour decides to get into her bath at home before going to hospital, to formal use in a specially designed birthing pool. Informal use in a domestic bath or shower is often initiated by a woman herself to help her cope at home before her labour is well established.

Formal use implies either that a woman has actively chosen to use water as part of her plan for labour and/or childbirth or that a health professional, usually a midwife, has suggested use during established labour.

Why water use is promoted

Use of immersion in water during childbirth has largely been driven by pregnant and birthing women17 and supported by midwives. During the first stage of labour it is advocated to shorten labour and help a woman relax and cope with contractions, feel more in control, and to reduce intervention by health professionals3,18-21.

During the second stage, proponents use it to allow perineal tissues to stretch spontaneously, birth to occur with minimum intervention, and to provide the baby with a gentler transition into extra-uterine life. Expectant management of the third stage is likely if a woman is in water.

Limitations on water use

Many health professionals consider that water use during the first stage of labour in uncomplicated pregnancy is unlikely to harm the mother or baby22,23, whilst others have concerns about water use at any point in labour14.

Local clinical guidelines may restrict water use to women considered at ‘low’ obstetric risk7, and other aspects of care may be prescribed, for example when and how to monitor the temperature of the water, the degree of cervical dilatation at which to begin its use24, and whether the immersion is considered safe for all stages of labour6,25.

Problems associated with possible risk of infection or cross infection caused by amniotic fluid, blood, and faeces have been described26-28 and some hospitals have restricted use of birthing pools to women who have tested HIV negative during pregnancy29.

However, at a multi-disciplinary consensus meeting held in London in 1996, it was agreed that mandatory HIV testing for prospective users of birthing pools could be an extreme reaction to the perceived risks and that high standards of pool hygiene would be an appropriate way forward30. Local infection control guidelines should cover the use of water pools25,31 and procedures to minimise risk of cross infection13, 32.

It has been suggested that high water temperature can cause serious changes in feto-maternal haemodynamic regulation and fetal thermoregulation33. It has been reported that fetal tachycardia can be reduced by cooling the water34 and most providers and clinical guidelines specify a temperature range within which the water should be maintained during the first and second stage of labour7,35.

The prospect of a woman giving birth in water can cause anxiety about how to deal with unexpected emergencies such as shoulder dystocia, the need to avoid the baby inhaling water, or being unaware that the umbilical cord has been severed11.

Despite the fact that it denies women choice about birth, one response has been to limit water use to first stage only6. Development of agreed clinical protocols to deal with unexpected complications25 and providing training which allows3 staff to achieve relevant competencies is key to enabling real choice for women about use of water.

There are theoretical risks of increased blood loss, retained placenta, or water embolism, and professional advice is often to conduct the third stage out of water25.

Because water adds to the difficulty of estimating blood loss accurately, it has been proposed that blood loss would be more appropriately estimated as being either more or less than 500ml36 and that the overall physical condition of the woman should be used as the most important indicator to assess the impact of any bleeding37.

In summary, although not universally accepted, first stage water use is less controversial than immersion for the second or third stage of labour22,23,38.

The research evidence

The effects of water use during the first stage of labour on maternal and fetal outcomes have been evaluated in several randomised controlled trials4,9,10,12,13,39 with sample sizes ranging from 60 to 123934.

The use of water has been shown to reduce the rate of augmentation40; however, no trial has been large enough to measure the effect of water use on important neonatal outcomes such as perinatal death or other serious neonatal or maternal morbidity.

In addition, there has often been significant cross-over between study groups4,12, reducing the likelihood of identifying clear differences between women allocated to water use and those not.

A systematic review of eight trials41 indicated a statistically significant reduction in the use of pain relief with no such significant difference in the rate of operative deliveries or in neonatal outcomes.

It concluded that while the use of water in the first stage of labour can be of benefit to some women, there is no evidence at present to support or not support a woman’s choice to give birth in water.

Retrospective comparison has been made of women who have used water with those who have not42,43.

However, there are considerable difficulties in interpreting such studies because of the possibility that the results are inherently biased.

In the same way, findings of cohort studies which suggest benefit for water use in terms of pain relief and increased rate of cervical dilatation44-47, or those which indicate differences in rates of maternal and neonatal infection48-50, are also open to criticism.

A recent study16 compared neonatal and maternal morbidity and mortality for spontaneous singleton births that took place in water or on land.

This was an observational study over a nine year period and data were obtained through standardised questionnaires for 9,518 births, of which 3,617 were waterbirths and 5,901 landbirths.

Statistically significant differences were identified between the two groups; women who gave birth using water were less likely to suffer serious perineal trauma, use no analgesia and have a lower blood loss than women in the landbirth group.

Maternal and neonatal infection rates were the same for both groups, but more landbirth babies had neonatal complications requiring transfer to an external NICU.

During the study, there were neither maternal nor neonatal deaths related to spontaneous labor.

The authors acknowledge the potential bias that could arise from the self-selection issue but argue that this is well accounted for in the analysis.They conclude that waterbirths are associated with low risks for both mother and child when obstetrical guidelines are followed.

Another study51 based in a centre for low risk women was a retrospective case review over a five year period of 1355 births in water.

When compared with land births over a corresponding period, women who gave birth in water had significantly fewer episiotomies with no evidence of a corresponding rise in lacerations, a reduction in the length of the first stage of labour, no increase in the risk of acquired infection or aspiration pneumonia and considerably lower levels of analgesia use.

Neonatal condition assessed by arterial cord blood pH, base excess and birth weight showed no differences.The authors conclude that this represents a realistic option for women at low risk of complications.

Many reports about water use are case series1,20,52-62 and focus on perceived benefits of water use for the mother, her baby and birth attendant.

These include shorter labour52, less use of pharmacological analgesics46,53, less intervention by care givers19, lower rate of perineal trauma60-62, and increased satisfaction with the experience of labour and birth54.

By contrast, some case reports have highlighted serious problems such as fetal overheating33,34, neonatal sepsis28, near drowning63 or death64.

Overall, reviews of the evidence21,23,65,66 conclude that appropriately large-scale research is still required to evaluate rigorously the physiological effects13, clinical outcomes, and economic impact of water use.

What we don’t know

The current evidence about water use remains quite heavily dependent on case series and comparison studies that include varying sized samples.

Therefore, reliable evidence about efficacy and effectiveness is still equivocal67.

  • Outstanding issues which require evaluation include:
  •  is water use causally associated with an increase in perinatal mortality or serious perinatal morbidity?
  •  at what dilatation should a woman be advised to begin water use?
  •  does the size or shape of the water container affect outcomes?
  •  if water has an effect on important physical/psychological outcomes for mothers or babies, are there particular women who should avoid using water during labour?
  •  to what extent immersion in water affects the length of labour?

Implications for maternity

Water use during the first stage of labour is offered by the majority of maternity care provider units in the UK and most offer support for water birth8.

Introduction of, and sustained suppor t for, water use may have considerable implications for service governance68.

However, not all costs fall to providers of care; a substantial cost burden is likely to be borne by labouring women themselves during informal use in domestic baths and showers or by hiring specially designed pools for use in their home or in a maternity unit.

Most maternity units have installed a water pool for use in labour8 and although installation and maintenance of a specially designed pool in a maternity unit involves obvious financial cost, this may be offset if there is a reduction in analgesia and anaesthetic use44.

There is evidence that formal water use means that at least one midwife will be in constant attendance during the first stage of labour and that at least two will be in attendance for birth7.

This level of staffing may be difficult to sustain and may have implications for equity of care for women who do not use water22.

Clear strategies for the training, preparation and support of staff who offer use of water during labour are recognised as essential7,25,31,37,44.

Key components of these include clarification of the roles of different maternity health professionals, multi-disciplinary development of local protocols, development of guidelines for clinical practice, and short-term secondment of midwives to learn alongside practitioners skilled and experienced in water use.

Implications for practice

Women may choose to use immersion in water during labour and/or birth. Midwives and other maternity care workers should therefore be knowledgeable about the evidence in terms of potential advantages and disadvantages.

Given the current quality of reliable evidence, effective practice is likely to be informed and influenced substantially by shared experience and personal observation.

Disproportionate weight may therefore be placed on perceived disadvantages or advantages and credibility given to outcomes which may not be associated causally with water use.

Practitioners should be alert to the evolving evidence base which underpins the use of water.

  •  Immersion in water during childbirth is a care option women may wish to choose and which health professionals have a responsibility to discuss and support using clear and balanced information.
  •  As with any labour or birth, it is essential to maintain systematic, contemporaneous records and to monitor and record routine observations about the well-being of the mother and the fetus. These data should be used to audit care and gather information about outcomes.
  •  Water temperature should be measured regularly using a thermometer and recorded.The water temperature should be comfortable for the woman and should be not more than 37°C during the first stage of labour and between 36-37°C in the second stage.
  •  Maternal faeces, meconium and blood clots should be removed from the water using a sieve, and effective cleaning of pools before/after use should be carried out to minimise risk of infection or cross-infection.
  •  Birth in water: the baby should be born fully submerged and be brought gently and without delay to the surface so that he/she can make their first respiratory efforts in air.
  •  Comprehensive, large scale research is required to address questions about the safety and effectiveness of using water during labour and/or birth.

Reproduced from Midirs 2005, last revised Jan 2005, review date Jan 2007. Informed Choice is supported by the Royal College of Midwives and the National Childbirth Trust.

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The effect of waterbirth on neonatal mortality and morbidity: a systematic review protocol

8 December 2015:

Rowena Davies, RM, BA 1, 2

Deborah Davis RM, PhD1, 2

Melissa Pearce RM/RN, BNurs, GDipMid, GCertMid, MMidwifery2, 3

Nola Wong, RM/RN2, 3

1. Nursing and Midwifery, Faculty of Health, University of Canberra

2. The Australian Capital Regional Centre for Evidence Based Nursing and Midwifery Practice: an affiliate centre of the Joanna Briggs Institute

3. Centenary Hospital for Women and Children, Canberra

Corresponding author: 

Rowena Davies

u3053358@uni.canberra.edu.au

Review question/objective

The objective of this research is to systematically review the evidence regarding the effect of waterbirth, in comparison to land birth, on the mortality and morbidity of neonates born to low risk women.

Background

Waterbirth and water immersion in labor are two distinct phenomena; however they are often confounded. Some women use water immersion in labor as a strategy to manage their labor pain but leave the bath prior to the birth of their baby.

As the name implies, however, waterbirth occurs when a baby is born underwater. This can happen either intentionally or accidentally, for example when a woman uses water immersion during labor and remains in the water to birth her baby.

Although the definitions of waterbirth and water immersion are simple to separate, descriptions of their use during a woman’s labor are often merged. 1,2

Given this, it is not surprising that research attempting to describe the benefits and risks of both water immersion and waterbirth is interwoven.

In many instances, discussion of waterbirth is confused by focusing on the benefits of water immersion for the woman and the risks of waterbirth to the neonate, two separate issues.

Water immersion in labor

Water immersion in labor has been used by many generations of women and is common practice in many birthing suites.3 Current research describes benefits for women using water immersion in labor including: increased relaxation4, pain relief5,6, maximized maternal satisfaction7, reduced length of labor2,3,5,8,9, reduced intervention3,10,11, increased spontaneous birth 12,13 and reduced first and second degree perineal tears.13,14

The buoyancy enabled by the water allows women to move easier during labor and potentially optimizes labor progress.3,6 Water immersion may also be associated with improved uterine perfusion, less painful contractions and a shorter labor.3,15,16

A Cochrane systematic review of eight trials comparing water immersion in labor with controls showed that water immersion resulted in a significant reduction in epidural analgesia use (478/1254 versus 529/1245; risk ratio [RR] 0.90; 95% [Confidence Interval [CI] 0.82 to 0.99, six trials]), a reduction in duration of the first stage of labor (mean difference -32.4 minutes; 95% CI -58.7 to -6.13, seven trials) with no difference in assisted vaginal birth (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 (intact perineum, 236/678 versus 200/659, RR 1.16, 95% CI 0.99 to 1.35, five trials) or maternal infection (15/647 versus 15/648, RR 0.99, 95% CI 0.50 to 1.96, five trials). 5 There have been no studies that have identified any adverse effects of water immersion in labor for the woman or the neonate.

Waterbirth

The benefits to women of using water immersion in labor are evident. However, the practice of birth underwater remains controversial and the debate polarized, with research providing conflicting information and mixed results.

As a result of this confusion, many birthing units in Australia provide water immersion in labor as an option for women; however, implementing waterbirth policies remains a slow and complex process.17,18

The trend of waterbirth

The first recorded waterbirth occurred in France in 1803.19 After laboring for 48 hours, an exhausted woman used a warm bath and birthed a healthy baby.1 In the early 1980s, waterbirths became more popular as water immersion was promoted to help women relax and cope with their labor.20, 21

Currently, few women birth their baby underwater; however water immersion in labor is commonly available.20 Baths and birthing pools were integrated into the United Kingdom’s mainstream maternity units in 1992 after the House of Commons Health Committee recommended that all women have access to water for labor and birth.12

Their national practice guidelines also support the use of baths and birthing pools in labor.22 Within Australia, 14 of 19 birthing centres provide bath facilities.23 Further, waterbirth tends to be supported by midwives as it represents a birthing option congruent with midwifery philosophy.7,24

Concerns about waterbirth

In an uncomplicated pregnancy, water immersion is unlikely to harm the woman or her baby.5 Given this, many birthing units will restrict water immersion in labor to women with a low risk pregnancy.

Regarding waterbirth, commentators have developed a list of contraindications; however, due to a paucity of research in this area, this is based largely on opinion.18 Even so, the option to waterbirth remains restricted to women with a low risk pregnancy. Individual birthing units develop specific waterbirth protocols suiting their own circumstances and existing policy.

In a review of the evidence on waterbirth, Young and Kruske (2013) identified five main areas of concern: a perceived risk of neonatal water aspiration, neonatal and maternal infection, neonatal and maternal thermo-regulation, skills of attending midwives and emergency procedures in the event of maternal collapse. They concluded there was no evidence supporting these concerns.25

Although the practice of waterbirth has been linked to increased risk to the neonate1, 26-28 there is no high level evidence available to support this issue.20,29 The association between waterbirth and adverse neonatal outcomes comes largely from case reports. 28,30,31

These highlight the potential risks to the neonate from waterbirth, including: neonatal respiratory distress, neonatal infection, umbilical cord avulsion, hyponatremia, hypoxic ischemic encephalopathy, fetal thermoregulation and water embolism.1,26,28,32,33

There are also numerous articles providing commentary about a perceived lack of adequate research and potential disregard for adverse neonatal outcomes following waterbirth.18,32, 34-36 Both case studies and commentary are at risk of author bias and represent a low level of evidence upon which to build waterbirth policy and protocol.

The above neonatal outcomes, as described within the literature, will form the basis of the reviewers search and discussion concerning potential neonatal outcomes following waterbirth.

Current evidence and policy

Simpson (2013)37 conducted a systematic review of neonatal outcomes following waterbirth; however, only two randomized controlled trials (RCT), two systematic reviews and case reports were reviewed.

A number of observational studies have been conducted on waterbirth but these were not included.37Also, no meta-analysis was conducted. The Cochrane systematic review by Cluett and Burns (2009) was similarly limited to RCTs. 5 Another systematic review, conducted in 2004, searched for complications that could be associated with waterbirth and was not limited to RCTs.1

They reviewed 16 articles and concluded that waterbirth may be associated with complications that are not seen with land birth, however, outcomes from water immersion and waterbirth are confounded.1 The quality and rigor of this review has also been called into question.35

There are two known RCTs comparing outcomes after waterbirth and land birth: an Iranian study of 106 women38 and a pilot study conducted in the UK.29 Both trials are small and therefore offer limited evidence. Woodward and Kelly (2009) reported that a larger RCT is possible and acceptable to women; however no further trial has been conducted hence raising concerns over feasibility.29

Published guidelines for health practitioners argue that there is insufficient evidence to guide waterbirth practice. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists offer a cautious review, suggesting that there is little evidence of waterbirth offering any benefits and advise caution when interpreting any current studies due to small sample sizes.39

The American College of Obstetricians and Gynecologists (2014) state that waterbirth “should be considered an experimental procedure that should only be performed within the context of an appropriately designed clinical trial with informed consent”40(p.914). However, it is unlikely that a RCT could ethically be conducted on this practice.

Other protocols agree that there may be no benefit, but argue that there is also no adverse effects directly attributed to waterbirth. A joint statement released by the Royal College of Obstetrics and Gynaecology (RCOG) and the Royal College of Midwives (RCM) support women laboring in water while acknowledging the lack of evidence supporting waterbirth and the rarity of complications.41

The Queensland Normal Birth guidelines also discuss waterbirth stating there is no evidence of increased adverse effects for the woman or fetus; however they acknowledge there is inadequate evidence to either support or not support, a woman’s choice to birth underwater.42

Young and Kruske (2012) confirm that Australia’s individual state policies lack contemporary, high quality evidence and do not encourage or provide guidance for women or their health care providers. 43

The current state of opinion and evidence of the benefits and risks of waterbirth for the neonate requires a thorough systematic review to be conducted. Current evidence is contradictory and the lack of robust systematic evidence regarding waterbirth allows the growth of conflicting opinion about its safety.

Given the scarcity of reliable evidence, anecdotal shared experiences and personal observation has influenced policy and practice. 20 A review of current literature focusing on high level evidence and maintaining clear and thorough search guidelines is needed to advance our understanding of the effect of waterbirth on neonatal outcomes.

Keywords

Waterbirth; neonatal outcomes; mortality; morbidity

Inclusion criteria

Types of participants

This review will consider studies that include low risk, healthy, pregnant women who labor and birth spontaneously, at term (37-42 weeks), with a single baby in a cephalic presentation.

Low risk pregnancies are defined as pregnancies with an absence of comorbidity or obstetric complication, such as maternal diabetes, previous caesarean section birth, high blood pressure or other illness. Women may be experiencing their first or subsequent pregnancy. The baby must also be well and without any comorbidity or complication.

Types of intervention(s)/phenomena of interest

The intervention of interest is waterbirth. The comparator is land birth. Women and their babies must be cared for by qualified maternity healthcare providers throughout their labor and birth. The birth setting must be clearly described but can include homebirth, hospital birth or birth center, either freestanding or attached to a hospital.

Types of outcomes

This review will consider studies that include the following neonatal outcome measures:

1. Neonatal mortality- stillbirth or neonatal death within 28 days of birth

2. Neonatal resuscitation or Respiratory Distress Syndrome within 24 hours of birth

3. Neonatal sepsis/infection, including fever and other infection markers, as defined within any studies, within seven days of birth

4. APGAR scores at one, five and ten minutes

5. Admission to Neonatal Intensive Care Unit or Special Care Nursery, including length of stay

6. Cord pH values – arterial and/or venous taken immediately following birth

7. Cord avulsion

8. Hyponatremia

9. Hypoxic ischemic encephalopathy

10. Birth injury

Types of studies

This review will consider studies that compare neonatal outcomes for both waterbirth and land birth including randomized controlled trials, quasi-experimental studies, prospective and retrospective cohort studies. Descriptive studies that do not include a comparator will be excluded.

Search strategy

The search strategy aims to find both published and unpublished studies. A three step search strategy will be utilized in this review. An initial search of MEDLINE and CINAHL will be undertaken followed by an analysis of the text words contained in the title and abstract, and of the index terms used to describe the article.

A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference lists of all identified reports and articles will be searched for additional studies.

Studies published in English within the last 15 years (from 1999) will be considered for inclusion. This ensures that retrieved studies will provide recent, up-to-date evidence that will reflect more contemporary practice and policy.

The databases to be searched include:

CINAHL

MEDLINE

Cochrane Database of Systematic Reviews and Central Register of Controlled Trials

Pubmed Clinical Queries

Web of Science

Scopus

Health Source Nursing

The search for unpublished studies will include:

ProQuest Theses and Dissertations

National Library database (Trove)

Google Advanced Search

Initial keywords to be used will be:

Waterbirth

Birth/s

Childbirth

Water

Underwater

Delivery

Births in water

Outcome

Effect

Neonatal

Neonate

Fetal

Infant

Newborn

Morbidity

Mortality

Assessment of methodological quality

Papers selected for retrieval will be assessed by four independent reviewers for methodological validity prior to inclusion in the review using the standardized critical appraisal instrument, the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion or with a fifth reviewer.

Data collection

Data will be independently extracted by two reviewers from each paper included in the review using the standardized data extraction tool from JBI-MAStARI (Appendix II). The data extracted will include specific details about the interventions, populations, settings, study methods and outcomes of significance to the review question and specific objectives. Authors of primary studies will be contacted for further data and to clarify unclear data as required.

Data synthesis

Quantitative data will, where possible, be pooled in statistical meta-analysis using JBI-MAStARI. All results will be subject to double data entry. Effect sizes, expressed as odds ratio (for categorical data) and weighted mean differences (for continuous data), and their 95% confidence intervals will be calculated for analysis.

Heterogeneity will be assessed statistically using the standard Chi square and also explored using subgroup analyses based on the different study designs included in this review. Where statistical pooling is not possible the findings will be presented in narrative form including tables and figures to aid in data presentation where appropriate.

Conflicts of interest

Reviewers have no conflict of interest.

Acknowledgements

Nil.

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The effects of immersion in water on labor, birth and newborn and comparison with epidural analgesia and conventional vaginal delivery

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.

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Response to joint ACOG and AAP Committee’s opinion regarding birthing pool use

May 2014

Response to joint American College of Obstetricians and Gynecologists (ACOG), and American Academy of Pediatrics (AAP) Committee’s opinion regarding birthing pool use during labour and waterbirth

A recent publication, ‘Immersion in water during labor and delivery’, by the US Committee on Obstetric Practice representing the American College of Obstetricians and Gynecologists and American Academy of Pediatrics, recommended that waterbirth should be ’considered an experimental procedure’ and only performed in the context of a randomised controlled trial 1.

Whilst this committee’s opinion accurately highlighted the lack of definitive randomised controlled trial (RCT) evidence (level 1) for waterbirth, citing the Cochrane review 2, its reignition of the debate about the ‘safety and efficacy’ of waterbirth was disappointingly biased, and partially incorrect. For example, it concludes that waterbirth ‘has not been associated with maternal or fetal benefit’, yet there is no evidence to suggest that it presents a greater risk than land birth for women who experience a straightforward pregnancy, or their newborn.

The committee opinion also indicated that most of the literature in support of waterbirth comprises ‘retrospective reviews of a single center experience, observational studies using historical controls [….] often in publications that are not peer reviewed’ 1. Geissbuehler and Eberard’s observational study, which included 3,617 waterbirths was in fact prospective and published in a peer reviewed journal 3.

Moreover, the committee made no mention of two additional prospective observational studies: one involving a UK sample of 8,924 women, which included 5,192 waterbirths 4, and the second study involving an Italian sample of 2,505 women, of whom 1,519 had a waterbirth 5. These studies were also published in peer reviewed journals.

There is reliable level 2 evidence showing an association between waterbirth and positive outcomes for women and their newborn. The UK study found that women, particularly nulliparae who had a waterbirth were more likely to experience a normal birth compared with women who used a birthing pool only during the first stage of their labour 4.

Normal birth is a composite outcome defined as including a spontaneous labour onset, no epidural and a spontaneous vaginal birth with no episiotomy 6, and its incidence has been identified as a marker of quality care 7.

This is an important finding in the context of a global initiative to reduce the overuse of intrapartum interventions and operative delivery.

Safety outcomes for women at low risk of childbirth complication showed no increase in the incidence of infection, or primary postpartum haemorrhage, and a reduction in operative delivery 3-5, 8. Findings of a reduced incidence of intrapartum interventions such as requirement for augmentation, pharmacological analgesia, and episiotomy indicate that waterbirth is also efficacious 3-5.

Results for neonates born in water to women at low risk of childbirth complication show no associated risk of increased morbidity or mortality in relation to infection, resuscitation, or NICU admission compared to land birth 3-5, 8. The committee opinion paper cited a small number of case studies that reported newborn ‘near-drownings’ following waterbirth.

This term has been used to describe a phenomenon whereby some babies born in water present with respiratory distress in the hours following birth; a condition that may self-resolve or require admission to NICU for oxygen therapy. In the term infant, this is usually caused by delayed lung aeration, and known as transient tachypnoea of the newborn (TTN) 9.

The large prospective observational studies, and a paediatric survey of 4,032 waterbirths found no increase in the incidence of transient tachypnoea of the newborn compared with land birth 3-5, 10.

Waterbirth studies have reported a low incidence of umbilical cord snap during waterbirth 4, 10, 11. However, data have not been collected for this complication during land birth, which currently precludes making comparisons.

As with all aspects of childbirth, and irrespective of high quality care provision, unforeseen adverse events shall always occur, and waterbirth is no exception.

It is incumbent upon caregivers to ascertain that it poses no added risk, or harm. Birthing pool use has gained in popularity among women and midwives in several countries, particularly among those working in midwifery led care settings. Further level 1 research is required to examine a number of factors in more detail.

For example, we need to explore further if waterbirth has the potential to facilitate normal birth. It is also necessary to compare the incidence of umbilical cord snap at, and transient tachypnoea of the newborn following waterbirth versus land birth. Another important area that we need to know more about is the acceptability of waterbirth to women and midwives.

Available level 2 evidence for waterbirth provides an important basis to inform pertinent outcome measures for a future randomised controlled trial.

In the meantime however, there is no reliable available evidence to indicate that waterbirth presents an increased risk factor compared with land birth for women who experience a straightforward pregnancy. There is therefore no reason to deny them the choice of using a birthing pool during the first or second stage of their labour in their planned place of birth.

Maternal choice in childbirth is a human right 12.

The right for women to choose is endorsed by the UK’s position statement regarding birthing pool use during labour and waterbirth 13, as reiterated in a recent BMJ news item in response to this Committee Opinion from the US 14.

References

1.      American College of Obstetricians and Gynecologists, American Academy of Pediatrics. Immersion in water during labor and delivery. Committee opinion Number 594, April

2014  [cited 2014 26th March]; Available from: http://www.acog.org/Resources_And_Publications/Committee_Opinions/Committee_on_Obstetric_Practice/Immersion_in_Water_During_Labor_and_Delivery

2.      Cluett E, Burns E. Immersion in water in labour and birth Cochrane Database Syst Rev  2009 22nd October 2009 [cited 2013 20th January ]; CD000111.pub3.]. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000111.pub3/pdf

3.      Geissbuehler V, Stein S, Eberhard J. Waterbirths compared with landbirths: an observational study of nine years. Journal of Perinatal Medicine. 2004; 32(4): 308-14.

4.      Burns EE, Boulton MG, Cluett E, Cornelius VR, Smith LA. Characteristics, Interventions, and Outcomes of Women Who Used a Birthing Pool: A Prospective Observational Study Birth. 2012; 39(3,): 192-202.

5.      Henderson J, Burns EE, Regalia AL, Casarico G, Boulton MG, Smith LA. Labouring women who used a birthing pool in obsteric units in Italy: prospective observational study. BMC Pregnancy Childbirth. 2014; 14(1): 17.

6.      Maternity Care Working Party, Royal College of Obstetricians and Gynaecologists, Royal College of Midwives. Making normal birth a reality; consensus statement.  2007  [cited 2011 9th September]; Available from: http://www.nct.org.uk/about-us/what-we-do/policy/normalbirth

7.      Dodwell M. Normal birth as a measure of the quality of care.  2010  [cited 2011 20th February]; Available from: http://www.nct.org.uk/about-us/what-we-do/policy/normalbirth

8.      Thoeni A, Zech N, Moroder L, Ploner F. Review of 1600 water births. Does water birth increase the risk of neonatal infection? J Matern Fetal Neonatal Med. 2005; 17(5): 357-61.

9.      Carpenter L, Weston P. Neonatal respiratory consequences from water birth. J Paediatr Child Health. 2012; 48(5): 419-23.

10.     Gilbert R, Tookey P. Perinatal mortality and morbidity among babies delivered in water: surveillance study and postal survey. British Medical Journal. 1999; 319(7208): 483-7.

11.     Cro S, Preston J. Cord snapping at waterbirth delivery. British Journal of Midwifery. 2002; 10(8): 494-7.

12.     Birthrights. Human rights in maternity care.  2014  [cited 2014 10th April]; Available from: http://www.birthrights.org.uk/library/factsheets/Human-Rights-in-Maternity-Care.pdf

13.     Royal College of Obstetricians and Gynaecologists, Royal College of Midwives. Immersion in water during labour and birth, Joint statement No.1.  2006  [cited 2014 10th April]; Available from: http://www.rcog.org.uk/womens-health/clinical-guidance/immersion-water-during-labour-and-birth

14.     McCarthy M. Underwater births should be limited to clinical trials, says US pediatric and obstetrics panel. .  2014  [cited 2014 27th March]; 348:[Available from: http://www.bmj.com/content/348/bmj.g2335

 

Diving in: a dip in the water for labour and birth policy debate

Megan Cooper RM, BHSc (Honours), Jane Warland RM, PhD Helen McCutcheon RM, PhD.

Abstract

Water immersion for labour and birth is becoming an increasingly attractive option for women.

However, with what has been described as a paucity of research, water immersion policies appear to lack the evidence to ensure confidence in their use, safety in their implementation and importantly, acknowledgement of women’s autonomy to utilise water for labour and birth irrespective of their perceived ‘risk’.

In touching on the difficulties experienced by maternity care providers working within a system largely dominated by a ‘risk adverse’ paradigm, the following paper will highlight the shortfalls of research surrounding water immersion for labour and birth and the difficulties of utilising policies informed almost entirely by this research.

The current paucity of rigorous evidence and the difficulties faced by maternity care providers facilitating the option, highlights that greater emphasis needs to be placed on gaining a substantial evidence-base to inform future water immersion polices with more weight given to both observational data and anecdotal experience.

Future research should focus on both quantitative and qualitative aspects of water use for labour and birth to ensure that policies incorporate the required risk/benefit analysis, the opportunity for shared and informed decision-making and ultimately, the facilitation of woman-centred care.

Should we throw out the bath water?

For many women water immersion (WI) during labour and birth is an attractive and sought after option of care.

Despite the availability of literature surrounding WI for labour and birth many argue that high quality research with which to measure risks and benefits is still lacking.

As the option has become increasingly available, the development of policy to guide and inform care providers in the safe practice of WI for labour and birth has become necessary.

Consequently, policies appear to have been derived from what some describe as a less than substantive evidence-base (Cluett and Burns, 2009).

This has elicited debate as to whether the practice itself and therefore the policies currently informing the practice reflect the required foundational evidence to fulfill the ideal of evidence-based practice.

In touching on the current difficulties experienced by care providers working within in a ‘risk averse’ system the following paper will briefly explore WI for labour and birth, highlight the perceived shortfalls of research pertaining to its practice and discuss some of the difficulties of undertaking research at the level that many believe is required.

The role of qualitative research in informing the practice of labour and birth in water will also be examined with particular reference to the goal of woman-centred care and the need for policy that is reflective of a holistic evidence-base and supportive of women’s experience, satisfaction and choice.

The practice of water immersion for labour and birth

Despite common belief, WI for labour and birth is not a new phenomenon, with history dating back to the Egyptian Pharaohs and the Minoans of Crete (Mackey, 2001). In the 1960’s, Igor Charkovsky, a Russian midwife, began experimenting with the use of water for labour and birth after realising the positive physical and physiological effects of WI (Houston, 2010).

The 1980s saw Michel Odent, a well-known French Obstetrician and arguably the pioneer of modern water birth, establish the first birthing unit allowing women access to baths during labour, many of whom also went on to birth in water

(Houston, 2010). His observations and documented accounts of witnessing women immerse themselves in warm water allowed him to become a major influential figure in the global water birth movement and in the education of practitioners who facilitate the option of WI.

The advantages and benefits of WI during labour and birth have for the most part, not been thoroughly investigated through rigorous research.

Documented benefits include reductions in pharmacological pain relief (Eberhard et al., 2005, Otigbah et al., 2000, Benfield et al., 2001, Cluett and Burns, 2009), reduced blood loss and perineal trauma (Cluett and Burns, 2009) as well as facilitation of dysfunctional labour (Benfield et al., 2010, Cluett et al., 2004).

It has long been held that water immersion facilitates ‘normal’ birth and the latest prospective and descriptive cross sectional research findings provide support for this belief (Burns et al., 2012, Dahlen et al., 2012).

Burns et al. (2012) found that there was a higher frequency of spontaneous birth in nulliparas and greater rates of normal birth in both nulliparous and multiparous women when water was used during labour and/or birth. More specifically, of the 8924 participants almost 90 percent had a spontaneous birth and of these 5192 (58.3%) of women birthed in water.

Further support for benefits of water use come from Dahlen et al. (2012). They found in their Australian descriptive cross sectional study that women birthing in water had lower rates of major perineal trauma and PPH ≥ 500 milliliters when compared with those who used a birth stool on land.

Improved APGAR scores at five minutes were also noted for babies born into water compared to those whose mothers birthed in a semi-recumbent position on land although the authors note that they are unsure as to whether a semi- recumbent position was favoured by practitioners when there were fetal concerns, thereby potentially impacting on the results.

However, what is perhaps most important in terms of these findings is that there were no documented increased adverse outcomes for mothers who utiliszed water during labour and birth nor were there statistically significant increases in unfavourable outcomes for babies born into water.

Anecdotal experience supports these benefits further, with women suggesting greater levels of satisfaction, sense of autonomy and care providers observing less use of pharmacological pain relief and the facilitation of the fourth stage of labour, particularly in the initiation of breastfeeding.

Qualitative researchers have also found that women who birth in water feel protected, safe, relaxed and in control (Benfield et al., 2010, Maude and Foureur, 2007, Benfield, 2002).

For example, one New Zealand interpretive study, conducted by Maude and Foureur (2007), highlighted that WI provided a ‘sanctuary’ or environment whereby women felt protected and sheltered from intervention and interference. Participants also voiced a reduction in the fear of the birthing process and pain.

For many maternity care providers, water use for labour and birth is viewed as a method of providing women an alternative method of pain relief, ease of position changes and relaxation (Gilbert and Tookey, 1999, Meyer et al., 2010, Maude and Foureur, 2007, Woodward and Kelly, 2004, Stark and Miller, 2009).

Although evident throughout the literature, the observation and experience of maternity care providers is often challenged against minimal scientific proof, which to date, is still not entirely definitive.

Conversely, many continue to challenge the use of water for labour and birth claiming that it is neither normal nor natural for land living mammals to birth into water and that there exist too many associated ‘risks’ and adverse outcomes to mother and infant (Kassim et al., 2005, Mammas and Thiagarajan, 2009, Carpenter and Weston, 2011, Pinette et al., 2004).

The most recent published adverse outcomes pertaining to the use of water immersion during labour and birth come from Soileau et al. (2013) and Menakaya et al. (2012). Soileau et al. (2013) documents a neonatal infection and subsequent neonatal demise post a home water birth attributed to a maternal diarrheal infection in the week prior to birth. The infection believed to have been transmitted to the neonate after the mother defecated in the bath during labour.

This provides justification and support for the use of policy and/or guidelines in guiding practitioners in the facilitation of the option. Furthermore, its draws attention to the knowledge and understanding practitioners must attain in order to make decisions that ensure both maternal and neonatal wellbeing and safety when water is used.

Although Menakaya et al. (2012) did not assess maternal or neonatal infections in their retrospective design of 216 Australian women birthing in water, they noted that babies born into water showed a statistically significant difference in APGAR scores less than or equal to seven at one minute and as well as admission to Special Care Nursery (SCN) post birth in the water birth group.

Interestingly, three of the neonates transferred to SCN were admitted for feeding difficulties, issues which cannot be definitely linked to water immersion, one was admitted post a mild shoulder dystocia which presumably required the woman to be evacuated from the bath prior to birth and one for meconium aspiration, suggesting the presence of meconium which is commonly cited contraindication to birthing in water.

The remaining infants were admitted for resuscitation and an apneic event, which are also not unique to infants born in water.

One infant in the control group was admitted to the SCN and was transferred for respiratory distress requiring the longest stay of all infants admitted to the SCN. These findings are dissimilar to those of Mollamahmutoglu et al. (2012) who found no instance of neonatal infection and no significant difference in admission to the Neonatal Intensive Care Unit (NICU) when comparing infants who were born in water with those who were not. These findings are indicative of the inconsistent and contradictory findings pertaining to the use of water for labour and birth across the literature.

As a result, empirical research has failed to provide a definitive risk/benefit analysis relating to WI for labour and birth particularly in terms of maternal and neonatal infection, neonatal SCN/NICU admission, perineal trauma and the incidence of neonatal drowning and water embolism, as examples.

Furthermore, the ongoing reference to ‘potential’, ‘possible’ and ‘theoretical’ risks throughout the literature as well as throughout policy and guideline documents creates difficulty and uncertainty as to what actually constitutes risk and what is deemed as safe when WI is utilised for labour and/or birth (Kvach and Martonffy, 2012, Mackey, 2001, Pinette et al., 2004).

Watering down practice

Maternity care providers aim as far as possible, to deliver care which is women- centered (Carolan and Hodnett, 2007). Woman-centered care (WCC) incorporates the requirement of a woman making informed choices about all aspects of her care through the sharing of information (Leap, 2009).

Maternity care providers hold information that is vital to the woman but given the need to work within protocols and guidelines, may at times provide information to meet institutional and personal expectations and commitments resulting in what Carolan and Hodnett (2007) describe as “rule following and avoidance of responsibility”.

Although not necessarily a deliberate attempt to limit the information and options available to women, difficulties can arise as maternity care providers walk the fine line between meeting obligations as the woman’s advocate and the demands of institutional policies, guidelines and regulations.

Consequently care providers may forsake their role as the woman’s advocate, and instead support an environment that fosters informed compliance (Carolan and Hodnett, 2007).

Unfortunately the ideal of woman-centredness is often relinquished particularly as birth has become viewed a process that requires management and medical influence (Kitzinger, 2006, Davis-Floyd, 2001).

The burden of ‘proof’ and necessity of evidence to support or refute ‘alternative’ options irrespective of women’s requests and subjective knowingness that they work (Klein et al., 2006) has been significant in the debate surrounding water immersion for labour and birth.

Many of the benefits that water provides the labouring and birthing woman are also what may deter care providers from offering it as an option. Women and care providers alike, have suggested that water provides safety, sanctuary and distance from the rest of world allowing women a sense of control and ownership over their labour and birth (Maude and Foureur, 2007). However, this protection from intervention and intrusion

ultimately means that the contemporary methods of monitoring and gauging progress are no longer as accessible or practical. For many practitioners the inability to monitor and assess women as they normally would results in fear, not only of litigation and ‘what if’s’ (Garland, 1919), but also of the practice itself.

Combatting fear and anxiety could be as easy as encouraging care providers to witness women using water during labour and birth, but opinion and bias in disfavour of water immersion demands the current ‘gap’ in research be bridged.

Furthermore, ethical practice calls for practitioners to dissociate personal bias and views from their practice to ensure women’s autonomy and ability to exercise choice are not downplayed or absent in the facilitation of care (ANMC, 2008, ANMC et al., 2008).

This issue is further complicated by the political climate within which maternity care now exists. Despite many care providers supporting the implementation and practice of WI for labour and birth and having the capacity and accreditation to facilitate the practice, they may be restricted by the lack of institutional resources and support (Garland, 2011) and most commonly, policy that is derived from an aversion of risk and research that has yet to determine with any certainty the safety of using water for labour and birth.

WI for labour and birth, despite putting what feels like an ‘alternative’ slant on care, has the potential as a practice and option of care, to assist care providers such as midwives to re-recognize normal physiological birth and subsequently work towards fulfilling the ultimate goal of woman-centred care.

A drought of evidence?

Water birth, in particular, is frequently associated with perceived risks and dangers and for this reason its use continues to be challenged relative to safety implications for mother and infant as has previously been discussed (Pinette et al., 2004, Kvach and Martonffy, 2012).

The conundrum is yet to be resolved particularly given the perceived paucity of definitive evidence. Yet the option is becoming increasingly demanded and therefore available and as a result, policies are in place to guide care providers in its facilitation, which are probably based (at least in part) on this limited evidence.

Although a number of attempts have been made to undertake research at the ‘gold’ standard, randomised controlled trials (RCTs) examining WI for labour and birth have suffered from less than optimal sample sizes, selection bias or poorly controlled confounding factors in groups of low risk women who are usually highly passionate and motivated (Woodward and Kelly, 2004, Schroeter, 2004, Cluett and Burns, 2009).

This is evident in the latest Cochrane review that included only 12 suitable studies, and of these, only three examined the use of water during second stage of labour (Cluett and Burns, 2009). Further to this there is currently no population level data being collected anywhere in the world about outcomes of WI nor even how many women choose to use WI in labour and/or birth in water (Pinette et al., 2004).

Undertaking the recommended research on WI and birth particularly such as the RCT suggested by Davies (2010) is complicated given that randomising for such a study brings about ethical and moral concerns.

Hendrix et al. (2009) found this to be the case in their Dutch questionnaire-based study assessing women’s reasons for not participating in an RCT investigating home birth versus hospital birth. Eighty-four women indicated that they did not participate due to a concern that they would be randomised to the ‘wrong’ group.

Woodward and Kelly (2004) attempted to overcome women’s reluctance to participate in their pilot RCT comparing water birth with land birth by including a ‘preference arm’. Their results indicated there were no significant difference noted between women who were randomised and those who chose the ‘preference arm’ and therefore concluded that women would be happy to be randomised in future and similar trials.

However, criticism of this RCT highlights that their sample size was too small and therefore underpowered to determine safety, particularly given that only 10 women birthed in water. Further to this, Keirse (2005) challenges the validity and generalisability given the ‘preference arm’ and the bias that meant only 20 of the 60 women who had a strong preference for one of the two options, were allocated to their preferred option.

Subsequently, randomisation of women to options of care, which elicit both emotive and somewhat passionate views, such as the use of WI in labour and birth, is not ethically or practically feasible particularly where recruitment of large numbers would be required to determine with any certainty the morbidity and mortality of the intervention.

The proposed undertaking of this type of randomised research is further complicated by inconsistency across institutional policies in addition to funding, necessary infrastructure and available accredited staff (Garland, 2011).

Not only does this make it difficult to allow for the option and implementation of WI for labour and birth but it also inadvertently contributes to the lack of evidence in that accessibility is limited and therefore data on resulting outcomes, scarce. Furthermore, where it is consistently highlighted that high quality evidence is deficient, the question must be asked: who or what is informing the policies already in existence?

Initiating a wave of change

It is consistently highlighted that there is insufficient data to inform the practice of labour and birth in water, but is this really the case? It is clear that there is a paucity of evidence in terms of empirical investigation however volumes of anecdotal experience and observational data are available suggesting that water has significant and undeniable benefits to the women, and arguably to the baby.

Despite its availability, little weight is given to this valuable information, information that could be informing the movement forward and providing direction for future investigation of WI for labour and birth.

There is no denying that greater high level research would be advantageous to providing a definitive set of benefits and risks and therefore, greater insight into the relative safety of WI for labour and birth. However, is a RCT the right option?

The suggestion that rigorous evidence is needed to inform policies and guidelines with confidence and reliability could be attributed to what has been termed the ‘medicalisation’ of pregnancy and birth (Brubaker and Dillaway, 2009, Benoit et al., 2010) particularly where the measure of risk is at the forefront of maternity care facilitation.

However, in a risk-averse climate, adverse events whether recognised through well-constructed studies, auditing or anecdotal accounts, are generally the first to be documented so as to prompt review of practice.

Despite this, a search of the literature surrounding WI for labour and birth highlights very few documented adverse outcomes at any level of evidence and of those that are documented; the outcomes cannot always be definitively attributed to the use of water (Pinette et al., 2004, Cluett and Burns, 2009, Byard and Zuccollo, 2010).

What are readily available are anecdotal and observational accounts that suggest that WI has extensive benefits, not only to the woman but also to birth outcomes. It could therefore be argued that quantitative research alone is insufficient to provide answers to myriad of complexities, questions and queries relating to the practice of WI for labour and birth and therefore, insufficient when informing policies particularly where women choose to exercise self-determination and choice irrespective of their perceived risk.

Freeman and Griew (2007) touch on this in their review of one WI policy and its development. Their findings suggest that policy could further be enhanced by placing weight on the views and experiences of consumers and addressing the importance of informed and shared decision making.

This calls for attitudinal change not only to facilitate care that is woman-centred but also to ensure that women’s autonomy is factored into the development and implementation of policies underpinning practice.

The significance and value of qualitative evidence is slowly being realised, particularly in maternity care where WCC is the ideal. Despite this, empirical evidence is still commonly viewed as more rigorous and therefore more reliable.

This is none too clear in the hierarchies of evidence that fail to give weight to qualitative investigation (Spiby and Munro, 2009). However, as health care moves towards patient-centred models, or woman-centredness (Leap, 2009), as is the case in maternity care, there is the need for increasing weight to be also placed on experience and opinion particularly surrounding policy formation and care facilitation.

In light of this, a multi-faceted evidence-based approach to policy development and implementation of WI for labour and birth is likely to be advantageous.

However, before recommendations can be made, a critical analysis of existing policies and their development should occur in order to highlight whether the so-called scarcity of evidence poses difficulties for those involved in WI policy formation and to what extent policy facilitates and/or restricts water use practice and more importantly, women’s autonomy.

Pooling for the future

This paper has touched on the many shortfalls of WI research to date as well as foreseeable difficulties of future research surrounding WI for labour and birth. Future research requires greater emphasis on both the quantitative and qualitative aspects of water use for labour and birth to ensure that policies incorporate both the risk/benefit analysis as well as the opportunity for shared and informed decision-making.

This includes greater exploration of the experiences and perceptions of women and importantly, an examination of current WI policies to determine how they are informed and developed and to what extent they facilitate the practice and support women’s autonomy.

Not only is there the potential for this all-encompassing research to assist maternity care providers in working with autonomy as practitioners and ensuring their ability to advocate for women but there is also the potential for the use of water for labour and birth to have positive outcomes in a system that has an ever increasing rate of intervention and deviation from what can be both a normal and natural process.

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MAMMAS, I. N. & THIAGARAJAN, P. 2009. Water aspiration syndrome at birth – report of two cases. J Matern Fetal Neonatal Med, 22, 365-7.
MAUDE, R. M. & FOUREUR, M. J. 2007. It’s beyond water: Stories of women’s experience of using water for labour and birth. Women and Birth, 20, 17-24.
MENAKAYA, U., ALBAYATI, S., VELLA, E., FENWICK, J. & ANGSTETRA, D. 2012. A retrospective comparison of water birth and conventional vaginal birth among women deemed to be low risk in a secondary level hospital in Australia. Women Birth.
MEYER, S. L., WEIBLE, C. M. & WOEBER, K. 2010. Perceptions and practice of waterbirth: a survey of Georgia midwives. J Midwifery Womens Health, 55, 55-9.
MOLLAMAHMUTOĞLU, L., MORALOĞLU, Ö., ÖZYER, Ş., SU, F. A., KARAYALÇıN, R., HANÇERLIOĞLU, N.,
UZUNLAR, Ö. & 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 The Turkish German Gynecological Association, 13, 45-9.
OTIGBAH, C. M., DHANJAL, M. K., HARMSWORTH, G. & CHARD, T. 2000. A retrospective comparison of water births and conventional vaginal deliveries. Eur J Obstet Gynecol Reprod Biol, 91, 15-20.
PINETTE, M. G., WAX, J. & WILSON, E. 2004. The risks of underwater birth. Am J Obstet Gynecol, 190, 1211-5.
SCHROETER, K. 2004. Water births: a naked emperor. Pediatrics, 114, 855-8.
SOILEAU, S. L., SCHNEIDER, E., ERDMAN, D. D., LU, X., RYAN, W. D. & MCADAMS, R. M. 2013. Case report: Severe disseminated adenovirus infection in a neonate following water birth delivery. J Med Virol, 85, 667-9.
SPIBY, H. & MUNRO, J. 2009. The development and peer review of evidence-based guidelines to support midwifery led care in labour. Midwifery, 25, 163-71.
STARK, M. A. & MILLER, M. G. 2009. Barriers to the use of hydrotherapy in labor. JOGNN: Journal of Obstetric, Gynecologic & Neonatal Nursing, 38, 667-675.
WOODWARD, J. & KELLY, S. M. 2004. A pilot study for a randomised controlled trial of water birth versus land birth. BJOG: An International Journal of Obstetrics and Gynaecology, 111, 537-545.

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Management of High Risk Women using Birthing Pool and Telemetry

There is evidence that water emersion in labour offers women a safe and effective form of pain relief in labour to those women who meet the criteria (NICE, 2007; NICE, 2014; Garland, 2011).

The use of telemetry provides women greater choice and control over their birth experience to facilitate the use of water (Birthing Pool or Bath) in labour and birth where their pregnancy and labour has been categorised as high risk and requires continuous fetal monitoring.

The Standard Operating Procedure (SOP) has been written to facilitate continuous fetal monitoring of high risk women in labour and birth who wish to use the birthing pool / water.

Telemetry is a wireless fetal monitoring device which facilitates continuous toco graph (CTG) monitoring where clinically indicated in the first and second stage of labour on a consultant led delivery suite.

Prior to the woman being offered the use of the birthing pool on the Delivery Suite consideration should be given to the plan of care and requirements of the woman and baby having reviewed the fully ante natal history.

The following lists are not exhaustive and full clinical assessment should be made on admission to delivery suite.

Click here for a copy of these guidelines

Water contamination and the rate of infections for water births

A. Thoeni*, F. Ploner and N. Zech 2008

Department of Gynaecology and Obstetrics, District Hospital of Vipiteno, Northern-Italy 

Abstract:

Objective: The potential for increased risks of infection is an important concern with water births.

We performed microbiological analyses on water samples taken from birthing pools before and after water births, and compared the rate of neonatal infection arising after water births with that arising after conventional delivery.

Materials and Methods:

In this prospective observational study beginning in 2001, water from the delivery pool was analyzed to determine the prevailing microorganisms.

Two water samples were taken at each delivery.

The first sample (sample A) was taken after the tub was filled with tap water; the second sample (sample B) was taken after the delivery.

The high rate of water contamination with Legionella pneumophila and Pseudomonas aeruginosa led us to install a filter system (Aquasafe –FilterR) into the supply hose for the birthing pool to reduce the water contamination.

This intervention significantly reduced the total microbial loading and there was no longer evidence of Legionella pneumophila.

Furthermore, we determined the rate of neonatal infections in infants delivered in water and compared it with those delivered conventionally out of the water.

Results:

Samples were obtained from 300 out of a total of 1,625 water deliveries, which took place between 2001 and 2007. Before the installation of a filter system, 29% of the A-samples showed bacterial growth with Legionella pneumophila,
22% with Pseudomonas aeruginosa, 18% with enterococci, 32% with coliforms, and 8% with Escherichia coli.

After the installation of the filter system, the water contamination decreased considerably:
– there were no further signs of Legionella bacteria, and Pseudomonas aeruginosa was found in only 3% and coliforms in 13% of the samples, respectively.

By comparing the microbiological composition of the B-samples before and after installation of the filter system, we concluded that the intervention did not influence the microbial loading of the water, which occurred during and as a result of
the whole delivery phase.

The microbiological loading of the water in the birthing pool after it was filled may have partly originated from the insufficient cleaning and disinfections of the birthing pool and after changing the cleaning records there was no longer any evidence of a significant microbial count (unpublished data).

Of the B-samples, 82% contained large amounts of coliforms, 64% contained Escherichia coli with concentrations of up to 105 CFU/100 mL, and 8-12% contained Pseudomonas aeruginosa.

Staphylococcus aureus and Candida spp were also
present in moderate amounts.

The rate of neonates treated with antibiotics for suspected infection on the basis of clinical symptoms (tachypnoea, skin color) or laboratory findings (CRP rise, leukocytosis) was 1.05% after water births (17 out of 1,625) compared with
1.75% (20 out of 1,139) after conventional delivery (p<0.05).

Conclusion:

Based on our results and the literature, water birth is a valuable alternative to traditional delivery when certain criteria are met and risk factors are excluded.

During water birth, faeces are discharged into the pool and the water is
contaminated with a variety of microorganisms.

However, contamination of the water with such microorganisms seems not to translate into an increased risk of neonatal infection.

Please click here to read the full document

Underwater birth and neonatal respiratory distress

Zainab Kassim, clinical research fellow in neonatology1, Maria Sellars, consultant in radiology2, Anne Greenough, professor of neonatology and clinical respiratory physiology

1 Department of Child Health, Guy’s, King’s and St Thomas’ School of Medicine, King’s College Hospital, London SE5 9RS, 2 Department of Radiology, King’s College Hospital, London

Introduction

In 1992 the House of Commons Select Health Committee’s report on maternity services recommended that all hospitals should provide women with the “option of a birthing pool where this is practicable.

“1 A subsequent surveillance study of all NHS maternity units between 1994 and 1996 found that 0.6% of all deliveries in England and Wales occurred in water.2

Rawal and colleagues have suggested that water births have become popular among mothers and midwives because the buoyancy and warmth of the water promotes natural labour while providing a non-invasive safe and effective form of pain management.3

Practitioners and parents should remember, however, that birthing pools pose potential risks for the baby. We report on a newborn baby who developed respiratory distress due to aspiration after an underwater birth.

Case Report

A full term male infant weighing 3150 g was born in the birthing pool of the labour ward of our hospital. His mother was a 34 year old, healthy primigravida who had had an uneventful pregnancy.

She had gone into spontaneous labour at 40 weeks’ gestation and had had no maternal fever during labour; at delivery the membranes had been ruptured for less than 18 hours. The baby was born underwater.

He required no resuscitation but, when reviewed at one hour, was grunting. As the grunting persisted, he was admitted to the neonatal intensive care unit at 3 hours of age. He had no fever but was tachypnoeic and had intercostal recession and nasal flaring.

He needed supplementary oxygen to maintain his oxygen saturation level at 92%; his need for supplementary oxygen persisted for nine hours. He was screened for infection and started on antibiotics (benzylpenicillin and gentamicin).

In view of his respiratory distress, which persisted for 48 hours, he was designated “nil by mouth” and fluid was administered intravenously until he had recovered. Chest radiography soon after admission showed widespread changes consistent with aspiration of the birthing pool water (figure).

Further radiography, on day 3, showed resolution of the abnormalities, and the infection screen was negative. The infant made a full recovery and, when seen as an outpatient at age 3 months, was free of symptoms.

Discussion

Some researchers have suggested that “babies can only drown when submerged, only if they are already severely compromised and literally at their `last gasp,’ as water simulates vagal inspiration receptors causing glottic closure.”4

In lambs, however, inhibitory mechanisms that prevent breathing until the lamb is in contact with cold air can be overridden by sustained hypoxia.5

Likewise, in a birthing pool, some babies with unrecognised hypoxia may gasp underwater. Indeed, the 1994 to 1996 survey cited two reports of water aspiration,2 and similar cases have been documented in the literature.6-8

Our case report emphasises the adverse effects of aspiration of water in birthing pools. Although such events seem uncommon, this may be the result of under-reporting.

Respiratory distress immediately after birth is common and has various aetiologies. Thus, unless a careful history is taken, the cause the respiratory distress may be misdiagnosed.9

We are confident that the case we report was due to aspiration of water as the infant developed symptoms soon after birth, with resolution by 48 hours.

In addition, there were no risk factors for infection or indeed any bacterial infection identified. Infection after water birth has been described.10-12

The baby in our case report was delivered after spontaneous labour at term, making transient tachypnoea of the newborn unlikely; indeed, the chest radiograph was consistent not with that diagnosis but with aspiration.

A systemic review of randomised trials has shown that immersion during labour is associated with significant reductions in the use of epidural, spinal, or paracervical analgesia and in women’s reports of pain, but highlighted there were insufficient data to determine the outcome from randomised trials of birth in water for women or their infants.13

In addition to water aspiration and subsequent pulmonary oedema,8 however, other adverse neonatal outcomes after water birth have been reported; these include water intoxication, hyponatraemia, hypoxic ischaemic encephalopathy, cord rupture with neonatal haemorrhage, and pneumonia.12 14

Women who have water births are usually considered to be “low risk,” and so they and their infants should have an excellent prognosis. Our case report and review of the literature confirm that water birth has risks for the newborn.

Practitioners and parents need to be aware of these potential risks so that mothers can make a fully informed decision about place of delivery.

Water birth can be associated with adverse effects in the newborn

Contributors: ZKand AG collected the clinical data, and MS col- lected the radiographic data. All authors contributed to writing the paper, and AG is the guarantor.

Funding: No special funding. Competing interests: None declared.


References

      1. House of Commons Health Select Committee. Maternity services. Second report. London: HMSO, 1992.
      2. Ruth E, Gilbert P, Tookey A. Prenatal mortality and morbidity among babies delivered in water: surveillance study and postal survey. BMJ 1999;319: 483- 7.
      3. Rawal J, Shah A, Stirk F, Mehtar S. Water birth and infection in babies. BMJ 1994;309: 511-2.
      4. Kitzinger S. Sheila Kitzinger’s letter from Europe: the waterbirth debate up-to- date. Birth 2000;27: 214-6.
      5. Johnson P. To breathe or not to breathe. Br J Obstet Gynaecol 1996; 103: 202- 3.
      6. Rosser J. Is water birth safe? The facts behind the controversy. MIDIRS Midwifery Digest 1994;4: 4-6.
      7. Barry CN. Water births. Could saline in the pool reduce the potential hazards? BMJ 1995;310: 1602.
      8. Nguyen S, Kuschel C, Teele R, Spooner C. Water birth—a near-drowning experience. Pediatrics 2002;110: 411-3.
      9. Bowden K, Kessler D, Pinette M, Wilson E. Underwater birth: missing the evidence or missing the point? Pediatrics 2003;112: 972-3.
      10. Rawal J, Shah A, Stirk F, Mehtar S. Water birth and infection in babies. BMJ 1994;309: 511.
      11. Nagai T, Sobajima H, Iwasa M, Tsuzuki T, Kura F, Amemura-Maekawa J, et al. Neonatal sudden death due to Legionella pneumonia associated with water birth in a domestic spa bath. J Clin Microbiol 2003:41: 2227-9.
      12. Pinette MG, Wax J, Wilson E. The risks of underwater birth. Am J Obstet Gynecol 2004;190: 1211-5.
      13. Cluett ER, Nikodem VC, McCandilish RE, Burns EE. Immersion in water in pregnancy, labour and birth. Cochrane Database Syst Rev 2005;(1)
      14. Schroeter K. Water births: a naked emperor. Pediatrics 2004;114: 855-8.

(Accepted 16 March 2005)

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Water birth, more than a trendy alternative: a prospective, observational study

Zanetti-Dällenbach, Rosanna1; Lapaire, Olav; Maertens, Anne; Holzgreve, Wolfgang; Hösli, Irene (2006) Archives of Gynecology and Obstetrics, Volume 274, Number 6, October 2006 , pp. 355-365(11)

Abstract:

To prospectively assess the effect of water birth on maternal and fetal outcomes in a selected low-risk collective of a tertiary obstetrical unit.

In this prospective observational study, 513 patients of a low-risk collective, who requested a water birth, were studied during the years 1998-2002. Primary outcome measurements included the maternal and fetal parameters.

Secondary outcome measurements comprised data on the incidence of water births in an interested, low- risk population in an academic hospital.

All groups were similar in terms of demographic and obstetric data. Significant differences were observed in maternal outcome parameters, which included the use of analgesia/anesthesia during labor, the duration of first and second stages of labor, perineal tears and episiotomy rate.

No differences were seen in all observed fetal outcome parameters including APGAR scores, arterial and venous pH, admission rate to neonatal intensive care unit and infection rate.

Water birth is a valuable and promising alternative to traditional delivery methods. The maternal and fetal outcomes were similar to traditional land births. However, currently there still exist some deficits in the scientific evaluation of its safety.

Therefore, the selection of a low-risk collective is essential to minimize the risks with the addition of strictly maintained guidelines and continuous intrapartum observation and fetal monitoring.

Based on our results and the literature, water births are justifiable when certain criteria are met and risk factors are excluded.

 

Shoulder dystocia at water birth

Nadine Massiah MBBS

Obstetrics and Gynaecology Department
Furness General Hospital
Barrow in Furness UK

Vincent Bamigboye MRCOG
Obstetrics and Gynaecology Department
Furness General Hospital
Barrow in Furness UK

Citation: N. Massiah & V. Bamigboye : Shoulder dystocia at water birth . The Internet Journal of Gynecology and Obstetrics. 2008 Volume 9 Number 1

Abstract

Health professionals providing obstetric care should be familiar with guidelines for shoulder dystocia. Regular drills are fundamental to the improvement of team work, enhancing communication skills and essential for good outcomes5.

Obstetric birthing simulators should be considered since they significantly improve competence in the management of shoulder dystocia6,7.

Learning and teaching are continuous processes in our practice. Optimal training is required to minimize morbidity and mortality of this obstetric complication.

Case Report

A 33 year old, para 1 lady presented in active labour at 40 weeks gestation. The abdominal findings were fundal height 39 cm, longitudinal lie and cephalic presentation.

Vaginal examination revealed cervical dilatation of 5 cm, occipito-anterior position of the foetal head at station minus two. The membranes were intact.

The booking investigations, dating and anomaly scans were found to be normal. The current pregnancy was uncomplicated. The first pregnancy and vaginal delivery were uneventful.

The pool was requested for labour and delivery. The labour progressed well to full dilatation. There was good descent of the head with active pushing. After delivery of the head, the shoulders were impacted. Mc Robert’s manoeuvre and suprapubic pressure were attempted without success.

The patient was moved from the birthing pool to the bed. Mc Robert’s manoeuvre, suprapubic pressure and downward traction of the head led to delivery of the anterior shoulder followed by the remainder of the body.

The time interval between the delivery of head and body was 3 minutes. The estimated blood loss was 350 mls. The neonate had a birth weight of 4200g with an Apgar score of 8, 9 and 10. Paediatric examination of the neonate was normal.

Discussion

The incidence of shoulder dystocia at water birth is 0.16%1. This case highlights that it is vital to be prepared for emergencies even with low risk women. They may occur in unfamiliar situations. Since the patient was wet, her safety whilst being moved to the bed was of great concern.

This was done carefully but quickly. It is estimated that the umbilical cord pH falls by 0.04 unit/min after delivery of the head2. A delay in delivery of the shoulders may result in cerebral hypoxia, cerebral palsy or death.

Forty seven percent of deaths from shoulder dystocia were within 5 minutes of delivery of the head3. The principles of management were widening of the pelvic diameters and repositioning the foetal shoulders into the oblique pelvic diameter to facilitate delivery4.

Health professionals providing obstetric care should be familiar with guidelines for shoulder dystocia.

Regular drills are fundamental to the improvement of team work, enhancing communication skills and essential for good outcomes5.

Obstetric birthing simulators should be considered since they significantly improve competence in the management of shoulder dystocia6,7.

Learning and teaching are continuous processes in our practice. Optimal training is required to minimize morbidity and mortality of this obstetric complication.

References

1. Thöni A, Zech N, Ploner F. Giving birth in the water: experience after 1,825 water deliveries. Retrospective descriptive comparison of water birth and traditional delivery methods. Gynäkologisch-geburtshilfliche Rundschau 2007; 47(2):76-80.

2. Wood C, Ng KH, Hounslow D, Benning H. Time – an important variable in normal delivery. Journal of obstetrics and gynaecology of the British Commonwealth 1973; 80(4):295-300.

3. Confidential Enquiries into Stillbirths and Deaths in Infancy. Fifth Annual Report. London: Maternal and Child Health Research Consortium, 1998. (s)

4. Draycott TJ, Fox R, Montague IA. Shoulder dystocia. RCOG Guideline No. 42. London:RCOG 2005.

5. Sorensen SS. Emergency drills in obstetrics: reducing risk of perinatal death or permanent injury. JONAS Healthcare Law Ethics and Regulation 2007; 9(1):9-16.

6. Deering S, Poggi S, Macedonia C, Gherman R, Satin AJ. Improving resident competency in the management of shoulder dystocia with simulation training. Obstetrics and Gynecology 2004;103(6):1224-8

7. Crofts JF, Bartlett C, Ellis D, Hunt LP, Fox R, Draycott TJ. Training for shoulder dystocia: a trial of simulation using low-fidelity and high-fidelity mannequins. Obstetrics and Gynecology 2006; 108(6):1477-85.

The use of water during childbirth – MIDIRS

Since the early 1980s use of immersion in water during labour and birth has been increasingly promoted to enable women to relax, help them cope with pain, and maximise their feelings of control and satisfaction1-4.

In 1992 the House of Commons Health Committee recommended all hospitals provide the option of a birthing pool where practicable5. Currently few women give birth in water but the option of immersion or showering during the first stage of labour is commonly available.6-8

Although problems have arise which have been attributed to water use, the results of the most formal evaluations have not clearly associated water use with harmful outcomes for mother or baby 3,9-13.

The lack of robust evidence of harm or benefit means that childbearing women and health practitioners alike are subject to conflicting opinion about the usefulness and safest of water, particularly for birth.

However, a recent observational study over a nine year period concluded that ‘waterbirth was associated with low risks where obstetric guidelines were followed’16.

At present in the UK there is no reliable measurement of the rate of birth in water.
A national survey of maternity units in the UK in 2002 found that 63% (216/342) had a birthing pool8; 67% (228/342) reported having at least one midwife trained to provide support for women giving birth in water and 36% (121/342) said that at least half of the midwives working in their unit were trained to support birth in water.

How is water used during labour?

Water use ranges from informal, for example when a woman in early labour decides to get into her bath at home before going to hospital, to formal use in a specially designed birthing pool. Informal use in a domestic bath or shower is often initiated by a woman herself to help her cope at home before her labour is well established.

Formal use implies either that a woman has actively chosen to use water as part of her plan for labour and/or childbirth or that a health professional, usually a midwife, has suggested use during established labour.

Why water use is promoted

Use of immersion in water during childbirth has largely been driven by pregnant and birthing women17 and supported by midwives. During the first stage of labour it is advocated to shorten labour and help a woman relax and cope with contractions, feel more in control, and to reduce intervention by health professionals3,18-21.

During the second stage, proponents use it to allow perineal tissues to stretch spontaneously, birth to occur with minimum intervention, and to provide the baby with a gentler transition into extra-uterine life. Expectant management of the third stage is likely if a woman is in water.

Limitations on water use

Many health professionals consider that water use during the first stage of labour in uncomplicated pregnancy is unlikely to harm the mother or baby22,23, whilst others have concerns about water use at any point in labour14.

Local clinical guidelines may restrict water use to women considered at ‘low’ obstetric risk7, and other aspects of care may be prescribed, for example when and how to monitor the temperature of the water, the degree of cervical dilatation at which to begin its use24, and whether the immersion is considered safe for all stages of labour6,25.

Problems associated with possible risk of infection or cross infection caused by amniotic fluid, blood, and faeces have been described26-28 and some hospitals have restricted use of birthing pools to women who have tested HIV negative during pregnancy29.

However, at a multi-disciplinary consensus meeting held in London in 1996, it was agreed that mandatory HIV testing for prospective users of birthing pools could be an extreme reaction to the perceived risks and that high standards of pool hygiene would be an appropriate way forward30. Local infection control guidelines should cover the use of water pools25,31 and procedures to minimise risk of cross infection13, 32.

It has been suggested that high water temperature can cause serious changes in feto-maternal haemodynamic regulation and fetal thermoregulation33. It has been reported that fetal tachycardia can be reduced by cooling the water34 and most providers and clinical guidelines specify a temperature range within which the water should be maintained during the first and second stage of labour7,35.

The prospect of a woman giving birth in water can cause anxiety about how to deal with unexpected emergencies such as shoulder dystocia, the need to avoid the baby inhaling water, or being unaware that the umbilical cord has been severed11.

Despite the fact that it denies women choice about birth, one response has been to limit water use to first stage only6. Development of agreed clinical protocols to deal with unexpected complications25 and providing training which allows3 staff to achieve relevant competencies is key to enabling real choice for women about use of water.

There are theoretical risks of increased blood loss, retained placenta, or water embolism, and professional advice is often to conduct the third stage out of water25.

Because water adds to the difficulty of estimating blood loss accurately, it has been proposed that blood loss would be more appropriately estimated as being either more or less than 500ml36 and that the overall physical condition of the woman should be used as the most important indicator to assess the impact of any bleeding37.

In summary, although not universally accepted, first stage water use is less controversial than immersion for the second or third stage of labour22,23,38.

The research evidence

The effects of water use during the first stage of labour on maternal and fetal outcomes have been evaluated in several randomised controlled trials4,9,10,12,13,39 with sample sizes ranging from 60 to 123934.

The use of water has been shown to reduce the rate of augmentation40; however, no trial has been large enough to measure the effect of water use on important neonatal outcomes such as perinatal death or other serious neonatal or maternal morbidity.

In addition, there has often been significant cross-over between study groups4,12, reducing the likelihood of identifying clear differences between women allocated to water use and those not.

A systematic review of eight trials41 indicated a statistically significant reduction in the use of pain relief with no such significant difference in the rate of operative deliveries or in neonatal outcomes.

It concluded that while the use of water in the first stage of labour can be of benefit to some women, there is no evidence at present to support or not support a woman’s choice to give birth in water.

Retrospective comparison has been made of women who have used water with those who have not42,43.

However, there are considerable difficulties in interpreting such studies because of the possibility that the results are inherently biased.

In the same way, findings of cohort studies which suggest benefit for water use in terms of pain relief and increased rate of cervical dilatation44-47, or those which indicate differences in rates of maternal and neonatal infection48-50, are also open to criticism.

A recent study16 compared neonatal and maternal morbidity and mortality for spontaneous singleton births that took place in water or on land.

This was an observational study over a nine year period and data were obtained through standardised questionnaires for 9,518 births, of which 3,617 were waterbirths and 5,901 landbirths.

Statistically significant differences were identified between the two groups; women who gave birth using water were less likely to suffer serious perineal trauma, use no analgesia and have a lower blood loss than women in the landbirth group.

Maternal and neonatal infection rates were the same for both groups, but more landbirth babies had neonatal complications requiring transfer to an external NICU.

During the study, there were neither maternal nor neonatal deaths related to spontaneous labor.

The authors acknowledge the potential bias that could arise from the self-selection issue but argue that this is well accounted for in the analysis.They conclude that waterbirths are associated with low risks for both mother and child when obstetrical guidelines are followed.

Another study51 based in a centre for low risk women was a retrospective case review over a five year period of 1355 births in water.

When compared with land births over a corresponding period, women who gave birth in water had significantly fewer episiotomies with no evidence of a corresponding rise in lacerations, a reduction in the length of the first stage of labour, no increase in the risk of acquired infection or aspiration pneumonia and considerably lower levels of analgesia use.

Neonatal condition assessed by arterial cord blood pH, base excess and birth weight showed no differences.The authors conclude that this represents a realistic option for women at low risk of complications.

Many reports about water use are case series1,20,52-62 and focus on perceived benefits of water use for the mother, her baby and birth attendant.

These include shorter labour52, less use of pharmacological analgesics46,53, less intervention by care givers19, lower rate of perineal trauma60-62, and increased satisfaction with the experience of labour and birth54.

By contrast, some case reports have highlighted serious problems such as fetal overheating33,34, neonatal sepsis28, near drowning63 or death64.

Overall, reviews of the evidence21,23,65,66 conclude that appropriately large-scale research is still required to evaluate rigorously the physiological effects13, clinical outcomes, and economic impact of water use.

What we don’t know

The current evidence about water use remains quite heavily dependent on case series and comparison studies that include varying sized samples.

Therefore, reliable evidence about efficacy and effectiveness is still equivocal67.

  • Outstanding issues which require evaluation include:
  •  is water use causally associated with an increase in perinatal mortality or serious perinatal morbidity?
  •  at what dilatation should a woman be advised to begin water use?
  •  does the size or shape of the water container affect outcomes?
  •  if water has an effect on important physical/psychological outcomes for mothers or babies, are there particular women who should avoid using water during labour?
  •  to what extent immersion in water affects the length of labour?

Implications for maternity

Water use during the first stage of labour is offered by the majority of maternity care provider units in the UK and most offer support for water birth8.

Introduction of, and sustained suppor t for, water use may have considerable implications for service governance68.

However, not all costs fall to providers of care; a substantial cost burden is likely to be borne by labouring women themselves during informal use in domestic baths and showers or by hiring specially designed pools for use in their home or in a maternity unit.

Most maternity units have installed a water pool for use in labour8 and although installation and maintenance of a specially designed pool in a maternity unit involves obvious financial cost, this may be offset if there is a reduction in analgesia and anaesthetic use44.

There is evidence that formal water use means that at least one midwife will be in constant attendance during the first stage of labour and that at least two will be in attendance for birth7.

This level of staffing may be difficult to sustain and may have implications for equity of care for women who do not use water22.

Clear strategies for the training, preparation and support of staff who offer use of water during labour are recognised as essential7,25,31,37,44.

Key components of these include clarification of the roles of different maternity health professionals, multi-disciplinary development of local protocols, development of guidelines for clinical practice, and short-term secondment of midwives to learn alongside practitioners skilled and experienced in water use.

Implications for practice

Women may choose to use immersion in water during labour and/or birth. Midwives and other maternity care workers should therefore be knowledgeable about the evidence in terms of potential advantages and disadvantages.

Given the current quality of reliable evidence, effective practice is likely to be informed and influenced substantially by shared experience and personal observation.

Disproportionate weight may therefore be placed on perceived disadvantages or advantages and credibility given to outcomes which may not be associated causally with water use.

Practitioners should be alert to the evolving evidence base which underpins the use of water.

  •  Immersion in water during childbirth is a care option women may wish to choose and which health professionals have a responsibility to discuss and support using clear and balanced information.
  •  As with any labour or birth, it is essential to maintain systematic, contemporaneous records and to monitor and record routine observations about the well-being of the mother and the fetus. These data should be used to audit care and gather information about outcomes.
  •  Water temperature should be measured regularly using a thermometer and recorded.The water temperature should be comfortable for the woman and should be not more than 37°C during the first stage of labour and between 36-37°C in the second stage.
  •  Maternal faeces, meconium and blood clots should be removed from the water using a sieve, and effective cleaning of pools before/after use should be carried out to minimise risk of infection or cross-infection.
  •  Birth in water: the baby should be born fully submerged and be brought gently and without delay to the surface so that he/she can make their first respiratory efforts in air.
  •  Comprehensive, large scale research is required to address questions about the safety and effectiveness of using water during labour and/or birth.

Reproduced from Midirs 2005, last revised Jan 2005, review date Jan 2007. Informed Choice is supported by the Royal College of Midwives and the National Childbirth Trust.

References

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Characteristics, interventions, and outcomes of women who used a birthing pool

Ethel E. Burns, RM, MSc, Mary G. Boulton, PhD, Elizabeth Cluett, RM, PhD,
Victoria R. Cornelius, PhD, and Lesley A. Smith, PhD 2012

Background: Birthing pools are integrated into maternity care in the United
Kingdom and are a popular care option for women in midwifery-led units and at home.

The objective of this study was to describe and compare maternal characteristics, intrapartum events, interventions, and maternal and neonatal outcomes by planned place of birth for women who used a birthing pool.

Methods:

A total of 8,924 women at low risk of childbirth complications were recruited from care settings in England, Scotland, and Northern Ireland.

Descriptive analysis was performed. Results: Overall, 7,915 (88.9%) women had a
spontaneous birth (5,192, 58.3% water births), of whom 4,953 (55.5%) were nulliparas.

Fewer nulliparas whose planned place of birth was the community (freestanding midwifery unit or home) had labor augmentation by artificial membrane rupture (149, 11.3% [95% CI:9.6–13.1]), compared with an alongside midwifery unit (271, 22.7% [95% CI: 20.3–25.2]), or obstetric unit (639, 26.3% [95% CI: 24.5–28.1]). Results were similar for epidural analgesia and episiotomy.

More community nulliparas had spontaneous birth (1,172, 88.9% [95% CI: 87.1–90.6]), compared with birth in an alongside midwifery unit (942, 79% [95% CI: 76.6–81.3]) and obstetric unit (1,923, 79.2% [95% CI: 77.5–80.8]); and fewer required hospital transfer (265, 20% [95% CI: 17–22.2]) compared with those in an alongside midwifery unit (370, 31% [95% CI: 28.3–33.7]).

Results for multiparas and newborns were similar across care settings. Twenty babies had an umbilical cord snap, 18 (90%) of which occurred during water birth. Conclusions: Birthing pool use was associated with a high frequency of spontaneous birth, particularly among nulliparas.

Findings revealed differences in midwifery practice between obstetric units, alongside midwifery units, and the community, which may affect outcomes, particularly for nulliparas.

No evidence was found for a difference across care settings in interventions or outcomes in multiparas or in outcomes for newborns.

During water birth, it is important to prevent undue traction on the cord as the baby is guided to the surface. (BIRTH 39:3 September 2012)

The article contains useful studies of water births in the UK by the NHS.

Please click here to read the full article

 

 

 

Cochrane Review – Immersion in water

Background

Enthusiasts suggest that labouring in water and waterbirth increase maternal relaxation, reduce analgesia requirements and promote a midwifery model of care. Sceptics cite the possibility 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 (October 2008).

Selection criteria

Randomised controlled trials comparing any bath tub/pool with no immersion during labour and/or birth.

Data collection and analysis

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

Main results

This review includes 11 trials (3146 women); eight related to the first stage of labour, one to the first and second stages, one to early versus late immersion in the first stage of labour, and another to the
second stage.

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; odds ratio (OR) 0.82, 95% confidence interval (CI) 0.70 to 0.98, six trials).

There was no difference in assisted vaginal deliveries (OR 0.84, 95% CI 0.66 to 1.06, seven trials), caesarean sections (OR 1.23, 95% CI 0.86 to 1.75, eight trials), perineal trauma or maternal infection.

There were no differences for Apgar score less than seven at five minutes (OR 1.59, 95% CI 0.63 to 4.01, five trials), neonatal unit admissions (OR 1.06, 95% CI 0.70 to 1.62, three trials), or neonatal infection rates (OR 2.01, 95% CI 0.50 to 8.07, five trials).

A lack of data for some comparisons prevented robust conclusions. Further research is needed.

Please click here to read the full article

 

 

Randomised controlled trial of labouring in water compared with standard of augmentation for management of dystocia in first stage of labour

Elizabeth R Cluett, lecturer in midwifery1, Ruth M Pickering, senior lecturer in medical statistics2, Kathryn Getliffe, professor of nursing1, Nigel James St George Saunders, medical director3

Objectives

To evaluate the impact of labouring in water during first stage of labour on rates of epidural analgesia and operative delivery in nulliparous women with dystocia.

Design

Randomised controlled trial.

Setting

University teaching hospital in southern England.

Participants

99 nulliparous women with dystocia (cervical dilation rate < 1 cm/hour in active labour) at low risk of complications.

Interventions

Immersion in water in birth pool or standard augmentation for dystocia (amniotomy and intravenous oxytocin).

Main outcome measures

Primary: epidural analgesia and operative delivery rates. Secondary: augmentation rates with amniotomy and oxytocin, length of labour, maternal and neonatal morbidity including infections, maternal pain score, and maternal satisfaction with care.

Results

Women randomised to immersion in water had a lower rate of epidural analgesia than women allocated to augmentation (47% v 66%, relative risk 0.71 (95% confidence interval 0.49 to 1.01), number needed to treat for benefit (NNT) 5).

They showed no difference in rates of operative delivery (49% v 50%, 0.98 (0.65 to 1.47), NNT 98), but significantly fewer received augmentation (71% v 96%, 0.74 (0.59 to 0.88), NNT 4) or any form of obstetric intervention (amniotomy, oxytocin, epidural, or operative delivery) (80% v 98%, 0.81 (0.67 to 0.92), NNT 5).

More neonates of women in the water group were admitted to the neonatal unit (6 v 0, P = 0.013), but there was no difference in Apgar score, infection rates, or umbilical cord pH.

Conclusions Labouring in water under midwifery care may be an option for slow progress in labour, reducing the need for obstetric intervention, and offering an alternative pain management strategy.

Introduction

Slower than expected progress in the first stage of labour (dystocia) occurs in 20% of nulliparous women in labour and accounts for 20% of caesarean sections and 40% of instrumental deliveries, and results in longer hospitalisation.1 For women at low risk of complications, it marks the transition from midwifery to obstetric management.

Since proponents of active management first claimed the benefits of shorter labour and lower rates of caesarean section,2 3 debate has continued over conservative versus aggressive management and the medicalisation of birth.

Management strategies for dystocia vary from immediate augmentation4 5 to delayed intervention up to four hours after diagnosis.6-8 Comparison between strategies is difficult as specific features often differ; for example, one-to-one care is recognised to have beneficial effect on labour outcomes.9

Our current trial was based on two precepts. Firstly, that incomplete understanding of labour may lead to unnecessarily early intervention. Secondly, that anxiety and pain may trigger a stress response,10 leading to reduced uterine activity and dystocia.11

Labouring in water may ameliorate this stress response by aiding relaxation and pain relief. Few trials have evaluated labouring in water, perhaps because of the difficulty in randomising women who may have strong preferences.12

A Cochrane review concluded that, for women at low risk of complications, there was no clear evidence of advantage or disadvantage in using a pool in labour but further research was needed.13 Two national surveys concluded that labour and birth in water had no effect on perinatal mortality.14 15

In preparation for the trial reported here, we conducted a feasibility study comparing labour in water with augmentation and conservative management for women with dystocia,16 but conservative management was considered unacceptable by women and clinicians. Our current trial therefore compares labour in water with augmentation in nulliparous women with dystocia.

Participants and methods

Design

Our randomised controlled trial compared immersion in water during the first stage of labour after diagnosis of dystocia with augmentation, the standard management for dystocia. We conducted the trial between January 1999 and December 2000 in a large university teaching hospital in southern England with about 4500 births a year.

Study population

Nulliparous women with a diagnosis of dystocia (cervical dilation of < 1 cm/hour)—who at that time would routinely have been advised to have their labour augmented by amniotomy or oxytocin infusion, or both—were eligible for the trial if they were able to give informed consent, had received information about the trial during their pregnancy (a leaflet describing the trial was distributed to all nulliparous women antenatally), were in spontaneous, active labour, and were at low risk of complications (full term, singleton pregnancies, fetus in cephalic presentation, and no medical, obstetric, or psychiatric problems).

Intervention

After participating women were randomised, each management option consisted of a package of care provided by midwives, including one-to-one care. Labour progress was assessed by vaginal examinations every four hours and documented on a standard partogram. All women could request any form of analgesia available at any time.

Augmentation—Women in the augmentation group received the standard management for dystocia. Amniotomy was performed if the membranes were intact, and a midwife managed the labour for the next two hours unless otherwise clinically indicated.

If the membranes were already ruptured or progress was not satisfactory during the two hours after amniotomy, intravenous oxytocin was given, starting at 4 mU/min and doubled every 30 minutes, up to a maximum of 64 mU/min, until regular contractions (3-4 every 10 minutes) occurred. Continuous fetal monitoring was carried out.

Labour in water—Women allocated to labour in water used a permanent, acrylic, oval waterbirth pool measuring 154 cm by 184 cm by 77 cm and filled with still tap water without additives so that immersion was to above the breasts when sitting. Water temperature was maintained at 36.0-37.0°C.

The maximum stay in the pool before reassessment by vaginal examination was four hours. If labour progress was satisfactory (cervicaldilation 1cm/hour),subsequent care could continue in the pool if the woman wished, otherwise augmentation was advised.

Sample size

We based our estimate of the potential effect size on an audit of 50 nulliparous women with dystocia in May-July 1997, who would have met the trial inclusion criteria.

We concluded that 220 women would be required to detect an absolute reduction of 25% in the rate of epidural analgesia (from 60% to 35%) and an absolute reduction of 20% in the operative delivery rate (from 40% to 20%) with 90% power in 5% two sided tests.

The local incidence of dystocia in nulliparous women meeting our eligibility criteria was about five a week (260 a year).

In our pilot study we obtained a consent rate of 71%,16 but we anticipated a lower rate when all midwives undertook recruitment, and therefore planned a recruitment period of two years.

Randomisation and recruitment

We used a computer generated randomisation schedule in balanced blocks of 20. Concealment was ensured by an independent person putting allocation details in sequentially numbered, opaque, sealed envelopes.

Ten consecutively numbered envelopes were stored in the labour ward at any one time and audited daily to ensure they were intact.

After dystocia was diagnosed, a midwife who had received training in patient recruitment checked that the woman in question had received the information leaflet about the trial, assessed her eligibility for the study, and, if suitable, sought her informed consent.

When a woman agreed to participate the midwife opened the next trial envelope to allocate the woman to a treatment arm and to give her a unique trial number. Participation in the trial was recorded in the woman’s routine maternity records.

Outcome measures

Primary outcome measures were epidural analgesia and operative delivery (ventouse, forceps, or caesarean section).

Secondary measures included augmentation rates (receiving amniotomy or oxytocin, or both) and maternal or neonatal morbidity (any infection, admission to the neonatal unit, or condition that required medical care up to the 10th postpartum day).

Obstetric data were recorded in the maternity records by practitioners and abstracted after discharge from maternity care.

It was not possible to conceal allocation from clinical practitioners or at the time of data abstraction as care provided was clearly documented. However, as data were objective in nature and recorded contemporaneously observer bias was minimised.

We conducted a postpartum structured interview in the maternity unit to assess retrospectively the women’s experience of pain at 30 minutes after the intervention started and change in pain over the same time period (measured with visual analogue scales of 0 to 100 mm for pain experience and -50 mm to +50 mm for change in pain).

We did not assess pain concurrently because of the disruption to the women and midwives. We also assessed women’s satisfaction overall and in relation to privacy and freedom of movement (asked as separate questions) using four point Likert scales.

We chose to use a structured interview format to reduce potential bias because it was not possible to keep the interviewer blinded to women’s treatments as their comments made the allocation apparent.

Statistical analysis

We analysed results on an intention to treat basis. We compared rates of epidural analgesia and operative delivery between groups using Pearson’s 2 tests and presented results as relative risks with 95% confidence intervals. When numbers were small we calculated exact P values and confidence intervals in StatXact-5.

We produced numbers needed to treat to produce benefit in one woman and calculated confidence intervals as the inverse of the confidence interval about the absolute risk difference.

Confidence intervals around the numbers needed to treat for non-significant differences include the numbers needed to treat to produce harm,17 showing that results are not inconsistent with the intervention producing worse outcome.

We used Mann-Whitney tests to compare length of labour and women’s pain and satisfaction scores, and presented confidence intervals for differences in means.

A confidential summary of the safety data was prepared after 50 women had been randomised, and assessed by an obstetric consultant independent of the trial, who recommended that recruitment continue.

Results

Recruitment

Of 3825 nulliparous women who delivered in the unit during the two years of recruitment, 741 were defined as being at low risk of complications at the time of the diagnosis of dystocia (see figure). Consent was sought from 176 eligible women, of whom 99 (56%) agreed to participate, and were randomised.

The two groups of women showed no important differences in baseline characteristics (table 1). There was good adherence to the trial protocol, with 48 of the 49 women allocated to labour in water using the pool, and 48 of the 50 women allocated to standard care receiving augmentation.

The woman who declined to enter the water requested an amniotomy. Two women in the augmentation group progressed before augmentation could be started.

Primary outcomes

Twenty three women (47%) allocated to labour in water received epidural analgesia after randomisation compared with 33 (66%) in the augmentation group (relative risk 0.71 (95% confidence interval 0.49 to 1.01), number needed to treat 5) (table 2).

The numbers of operative deliveries (caesarean sections and ventouse and forceps deliveries) were similar in both arms of the trial, with 24 (49%) women allocated to labour in water receiving an operative delivery compared with 25 (50%) women allocated to augmentation (relative risk 0.98 (0.65 to 1.47), number needed to treat 98).

Secondary outcomes

Twenty five of the 27 women in the water labour arm who had made slow progress at the assessment four hours after recruitment received augmentation.

A further three women progressed slowly subsequently and also received augmentation. Seven women who progressed satisfactorily received an amniotomy for other indications.

The number of women who received augmentation (amniotomy or oxytocin) in the water labour arm was significantly lower than that in the standard care arm (35 (71%) v 48 (96%), relative risk 0.74 (0.59 to 0.88), number needed to treat 4) (table 2).

The mean duration of the first stage of labour was similar in the two groups, 10.47 hours in the water labour group and 10.26 hours in the augmentation group (table 3).

Women allocated to labour in water reported significantly lower mean pain scores at 30 minutes after start of the allocated management (49 mm v 64 mm) and a reduction in mean pain (-26 mm) compared with an increase for women receiving augmentation (12 mm).

Women allocated to labour in water were more likely to report satisfaction with freedom of movement (91% v 63%) and with experience of privacy (96% v 81%), but there was no difference between groups in overall satisfaction (table 3).

Maternal and neonatal wellbeing

Maternal and neonatal infection rates were similar in the two groups (table 4), as was neonatal condition at birth indicated by Apgar score and umbilical cord pH. Six neonates born to women in the water labour group were admitted to the neonatal unit compared with none in the augmentation group (P = 0.013).

The reasons for admission were: cardiac defects (1), hypothermia (2), fever (1), suspected infection on day 2 (1), and poor feeding on day 3 (1). There was a mean delay of 6 hours (range 2-10 hours) between women leaving the pool and birth.

With the exception of the infant with cardiac defects, all these neonates, who had required an operative delivery, were reunited with their mothers within 48 hours and experienced no subsequent problems.

Discussion

This is the first trial to evaluate the impact of labouring in water for nulliparous women with dystocia. Compared with women given standard augmentation, the women labouring in water had no difference in operative delivery rates and tended to receive less epidural analgesia.

Before this trial it had been suggested that as all the women would have dystocia, augmentation would be inevitable, along with longer labour, and/or assistance in the second stage of labour.

However, almost 30% of women in the water arm did not receive augmentation and 20% received no obstetric intervention, without evidence of longer labour, both of these rates being significantly different from the augmentation arm. In addition, women retrospectively reported less pain and increased satisfaction.

Our findings suggest that delaying augmentation in association with a supportive environment (water immersion) is acceptable to women with dystocia and may reduce the need for epidural analgesia without increasing labour length or operative deliveries.

This is important, as it has been suggested that women prefer earlier intervention.7

Also a management approach that reduces rates of augmentation and associated obstetric intervention may contribute positively to maternal physiological and psychological health: oxytocin infusion is known to increase the risk of uterine hyperstimulation and fetal hypoxia, and obstetric interventions are associated with lower maternal satisfaction.18

A reduced need for epidural analgesia and augmentation may enable staff and other resources to be used differently—for example, allowing more women to receive one-to-one care in labour.

Maternal and neonatal wellbeing

The trial was not large enough to detect differences in maternal and fetal morbidity. However, indicators of wellbeing were similar in the two groups, with the exception of increased admission to the neonatal unit after labour in water.

Possible reasons for this include the water immersion itself, the delay in intervention of up to four hours (even though this did not affect overall labour length), extra caution by practitioners when women were known to have laboured in water, or chance factors with no direct relation to the trial.

No other studies of labour in water have reported such an association: instead, they either did not provide data on admissions to neonatal units19 20 or reported only one admission21 or similar admission rates in both trial arms.22

Eckert et al reported an increased incidence of initial resuscitation measures with water immersion,22 but we found no difference in Apgar scores and blood gas analysis at birth.

Indeed, three of the admissions to the neonatal unit were between nine and 48 hours after delivery, while the three admissions immediately after birth were associated with temperature regulation.

Comparative studies of labour in water found no increase in admissions to neonatal units or other markers of neonatal distress.23-25 It is clearly important to ensure ongoing audit of neonatal outcomes for women who labour in water.

Limitations of study

Only 99 of the intended 220 women were recruited for a variety of reasons. In common with other trials18 epidural analgesia was the main reason why nulliparous women with dystocia were ineligible for our study (28%).

Local rates of epidural analgesia and their likely impact on recruitment should feature as part of the planning of any future trials involving labour management.

In our busy maternity unit recruitment was not a priority, and some eligible women were not invited to participate in our study. The main reason eligible women chose not to enter the trial was a preference for one or other form of care (40%).

This is a recognised problem, and consideration is needed on how this may affect the generalisability of our findings and ways to overcome recruitment problems.

Recruitment became more difficult towards the end of the trial because of the adoption of a more conservative approach to managing dystocia in the unit and the introduction of the modified World Health Organization partogram,6 which incorporates a delay between the identification of slow progress and augmentation.

During this delay midwives could facilitate ongoing conservative management; as a consequence, they were less willing to recruit women to the trial, knowing that half of the women would immediately receive augmentation.

Thus, the trial was not continued past the planned two years. The low recruitment rate contributed to the outcomes achieved, such as the lack of statistical significance in relation to the difference in rates of epidural analgesia.

    • What is already known on this topic

For women in normal labour, immersion in water is associated with less need for analgesia and increased satisfaction

Augmentation of labour, in particular oxytocin administration, is associated with hyperstimulation and decreased maternal satisfaction

    • What this study adds

For nulliparous women with dystocia (cervical dilation < 1 cm/hour), immersion in water for up to four hours seemed to reduce need for augmentation of labour, reduce pain, and increase satisfaction, without increasing overall length of labour or operative delivery rate

Water immersion may be an alternative option to early augmentation of labour

We thank the women who participated in the trial; the midwives and obstetric and support staff of the unit where the trial was conducted; research advisory group members Maggie Elliot and Debbie Gould; and Rona McCandlish for her support in preparing this paper.
Contributors: ERC was principal investigator and research midwife and was responsible for trial design and coordination, and data collection and analysis, supported by RMP and KG as research supervisors. NJS contributed to the initial idea and enabled the trial in the clinical setting.

All authors helped to write the paper. ERC acts as guarantor for the paper.
Funding: Southampton University Hospitals NHS Trust.
Competing interest: None declared.
Ethical approval: Approval was given by the local research ethics committee.

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