The use of water for labour and birth – Colchester University Hospital

Feeling relaxed, secure and in control and being able to move about freely can make
it more likely for you to have a quicker and more natural birth.

For some women using a birthing pool can offer all of these benefits.

Today more and more women are considering using water for pain relief in labour.

A midwife can support you in using a birthing pool at home or in our midwife-led units
at Colchester General Hospital and Clacton and Harwich hospitals in the community.

Using a birthing pool is likely to increase the chances of a normal vaginal delivery
and therefore we would like to offer this option to as many women as possible.

We have compiled this leaflet to give you and your partner relevant information about
labouring and giving birth in water.

Please talk to your midwife during the antenatal period who will be able to answer any questions you may have.

Please click here to read the full document

 

Guidelines for a safe water birth

Barbara Harper 2006

The aim of this guideline is to provide a review of information on labor and birth in water and to suggest possible strategies to minimize the potential hazards to mothers and infants.

It can also be used to promote the maternal and infant benefits, which may arise from choosing this type of birth experience, but are not easily quantifiable.

It is written with the belief that clinically sound, evidence based guidelines improve quality of care.

These recommendations are not intended to dictate an exclusive course of management or treatment.

They must be evaluated with reference to individual client’s needs, resources and limitations unique to the place of birth and variations in client choices.

Rationale

The therapeutic properties of warm water immersion have been known for centuries. Baths, showers and whirlpools have been used for comfort during labor for many years. Over the past two decades the use of warm water immersion for the birth of the baby has aroused interest in many countries and an increase in the number of women requesting this option for both hospital and out-of-hospital births is occurring.

Waterbirth International has reviewed the best available evidence and offers this guideline to assist midwives and women in their decision making process around the use of water immersion for labor and birth. The body of evidence is small but growing.

Evidence

Maternal and neonatal outcomes after water immersion for labor and birth have been assessed in two large surveys over a four year period in England and Wales (Alderdice, Renfrew & Marchant, 1995; Gilbert & Tookey, 1999) Researchers reviewed 4693 and 4032 births, respectively, where water immersion was used and found no difference in outcomes for women and their newborns compared to a cohort group of low risk women who did not use water.

The perinatal mortality rate for these births was comparable to other low risk births in the UK. (Gilbert and Tookey 1999). This study tried to estimate mortality and morbidity rates for babies delivered in water.

The data collected was compared to other sources of data providing similar estimates for babies delivered conventionally to low-risk women. They examined adverse outcomes, which were reported over a two-year period between 1994 and 1996 from approximately 4,000 births in water. 1500 consultant pediatricians were surveyed and asked to report any cases of baby deaths associated with waterbirth. None of the five perinatal deaths recorded among the waterbirths was attributable to delivery in water.

Admissions to special care baby units were slightly lower for the water-born babies than admissions for other low-risk babies. This was a landmark study in providing significant reassurance about the safety of waterbirth.

Other researchers (Burns 2001; Lenstrup et al, 1987; Rush et al,1996; & Waldenstrom et al, 1992) have made similar outcome reports. A recent Canadian randomized control trial reported women experienced less pain after water immersion than their non-immersion counterparts and over 80% of the water immersion group said they would use the tub in subsequent labors (Rush et al, 1996).

There have been a few highly controversial reports in the literature, especially in the journal Pediatrics on the negative effects of water immersion for babies. “Water Birth: a near drowning experience (Nuygen et al, 2002) suggests that every case of waterbirth should be evaluated as a possible fresh water drowning. The authors’ conclusions that the use of water for labor and birth may contribute to adverse outcomes should be viewed with considerable caution.

There are several methodological problems with this case study and these results are not congruent with the findings of many large trials. It is clear more research is needed into this form of care. But opinion pieces should be viewed at just that, opinion and not referred to as scientific or medical evaluation of the evidence.

In the absence of a substantial body of evidence on the use of warm water immersion for labor and birth, the potential advantages and disadvantages, which follow, are primarily derived from experience. This guideline will be updated as more evidence becomes available.

Eligibility

Water immersion for labor and birth should be available to all clients who request it, who have been screened and who have discussed the risks and benefits with their care provider. Some practices may choose to use a standard informed consent form for the use of warm water immersion.

Water Immersion Defined

Water immersion must be defined at providing a depth of water which enables the mother to sit in water that covers her belly completely and comes up to her breast level or kneel in water on her haunches which comes up to just below her breast level.

Any amount of water less than this does not constitute true immersion and will not create the buoyancy effect and produce the chemical and hormonal changes which enhance a more rapid labor. After an initial immersion of approximately thirty minutes the body responds by releasing more oxytocin, but only if the body experiences deep immersion, leading to buoyancy.

When to enter the bath in labor

It has been reported in the literature that labor slows down or stops if the woman enters the bath too soon. Guidelines were established to prevent a woman from entering the bath before the start of active labor, by definition: established labor pattern, dilation of the cervix to 4cm or greater and the need to concentrate during the contraction.

We argue that observation has led us to believe that a woman should be given the opportunity to use immersion as soon as her body and her brain have the desire to bathe. Women have been observed in very early labor relaxing, letting go of fear and progressing quickly to an active and pushing phase of their labor.

Using the water effectively often requires a “trial of water,” to see how the mother will respond. It has been noted with the advent of underwater continuous fetal monitoring that contraction patterns once thought to space out and become less frequent were in fact exactly the same in or out of the water. The mother’s response to those contractions in the water was vastly different from the response on the bed, thus making everyone believe that they were less intense.

The chemical and hormonal effects of immersion take effect after no less than twenty minutes and peak around ninety minutes. It is therefore suggested that a change of environment, such as getting out and walking be recommended after about two hours of initial immersion. The midwife can make an evaluation of the mother’s condition at that time.

Getting back in the water after thirty minutes will reactivate the chemical and hormonal process, including an sudden and often marked increase in oxytocin.
Dianne Garland, registered midwife, lead waterbirth researcher in England and the author of, ” Waterbirth: An Attitude to Care,” says the following:
” Just as labors can be slower or stop out of water so is true of water. Changes to the woman’s body are normal in labor and each of us will tolerate different lengths of first and second stage. Just as we all deal with different amounts of fatigue and stress, so each woman is individual and should be treated as such in labor.

The point of this with water labor and waterbirth is that as each woman is an individual, so her labor should be cared for, within the normal parameters set by ourselves as autonomous practitioners. Or within the maternity units where we work. Fundamental changes to normal practice may need to be made in units where active management of labor prevails.”

Summary of benefits for labor and birth in water

  • Facilitates mobility and enables the mother to assume any position which is comfortable for labor and pushing
  • Speeds up labor
  • Reduces blood pressure
  • Gives mother more feelings of control
  • Provides significant pain relief
  • Promotes relaxation
  • Conserves her energy
  • Reduces the need for drugs and interventions
  • Protects the mother from interventions by giving her a protected private space
  • Reduces perineal tearing
  • Reduces cesarean section rates
  • Is highly rated by mothers – typically stating they would consider giving birth in water again
  • Is highly rated by midwives
  • Encourages an easier birth for mother and a gentler welcome for baby

Theoretical Potential Disadvantages

  • Decrease in uterine contraction strength and frequency, especially if entering the bath too soon
  • Neonatal water aspiration
  • Maternal hyperthermia may contribute to fetal hypoxemia
  • Neonatal hypothermia
  • Cord immersion in warm water may delay vasoconstriction, increasing red cell transfusion to the newborn and promoting jaundice
  • Blood loss estimation and assessment not accurate
  • Maternal and Neonatal infection may be increase – not supported by the evidence
  • Risk of acquiring blood born infection or sustaining back injury for caregivers

    Recommended Criteria for the use of a water pool

  • An uncomplicated pregnancy of at least 37 weeks gestation
  • Established labor pattern – good regular contractions
  • Reassuring fetal heart tones
  • Absence of bleeding greater than bloody show
  • Spontaneous or on-going labor after misoprostol or Pitocin

    Contraindications for birth in a water pool

    There are no contraindications to labor in water, as evaluated by the literature and from experience. Immersion is a client/provider decision. Birth in water comes with a few “ABSOLUTE” contraindications and a few “CONTROVERSIAL” contraindications.

    Absolute contraindications

  • Pre-term labor
  • Excessive vaginal bleeding
  • maternal fever> 100.4, or suspected maternal infection
  • Any condition which requires continuous fetal heart rate monitoring
  • Untreated blood or skin infection
  • Sedation or epidural
  • Fearful Attendant
  • Inflexibility in the client

    Controversial contraindications

  • Meconium staining in amniotic fluid

    The presence of meconium should be evaluated with fetal well-being and taken by itself as a reason to ask the mother to leave the water. Meconium washes off the baby in the water. Baby can be suctioned as soon as it has been brought to the surface of the water. Some practices are now only limiting thick meconium cases.

  • HIV, Hepatitis A, B, C, GBS

    Evidence shows that HIV virus is susceptible to the warm water and cannot live in that environment. Proper cleaning of all equipment after the birth needs to be carried out. Hepatitis should be the discretion of the attending medical caregiver.
    There is absolutely no evidence that GBS positive cases should be asked to leave the water. Most hospitals allow IV antibiotic administration while in the water.

  • Herpes

    Some providers will cover the lesion, especially if it has peaked and is sloughing off. Others will require a cesarean. Some feel it is safer to deliver in the water due to the dilution effect of the water.

  • Breech or multiple births

    In the H. Surreys Hospital in Ostend, Belgium, frank breech is an indication for a waterbirth. Their vast experience has led them to believe that the absence of gravity, the warm water and the buoyancy create the perfect environment for a hands free breech birth. Labor in water for both breech and multiples is well documented and recommended. This should be a client/provider decision.

  • Shoulder Dystocia or Macrosomia with suspicion of Shoulder Dystocia

    This is usually considered an obstetric or midwifery emergency by most. Current protocols in most hospitals require the mother who is anticipating a large baby to leave the water. There is mounting evidence that providers find it is easier to assist a shoulder dystocia in the water. It is believed that tight shoulders happen more often because of mom or caregiver trying to push before the baby fully rotates. Better to wait a few contractions, with the head hanging in the water and allow baby to rotate. Because position changes in water are so much easier than dry land, a quick switch to hands and knees or even standing up with one foot on the edge of the pool helps to maneuver baby out. (research indicates that you can’t predict shoulder dystocia)

  • VBAC

    As the controversy over vaginal birth after previous cesarean section continues, it has been noted that mothers who labor for subsequent births have a much higher success rate in giving birth vaginally. Some hospitals refuse to allow women into the water because they don’t provide waterproof continuous fetal monitoring.

  • Intrathecal use

    A few hospitals will allow a mother into the water after receiving an intrathecal Monitoring of the baby is suggested as continuous, but some hospitals allow intermittent monitoring.

  • Induction or augmentation

    Many hospital practices will now allow mothers whose labors are initiated by Misoprostal or Pitocin to get in the pool as soon as a labor pattern is established.

    Some even allow mothers with a Pitocin drip to labor in water, as long as fetal heart rate assessment can be monitored with continuous underwater equipment.

  • Tight nucal cord

    Under no circumstances should the cord be clamped or cut under the water. Babies can be delivered through the cord and ‘unwound’ under the water. Be cautious of cord snapping.

  • Water temperature at time of birth

    Some providers will not allow women to birth in water that is lower than body temperature due to the possibility that the baby will attempt to inhale under the water from a change in temperature. There is no evidence that supports this theory, in fact there is more evidence that now shows that lower water temperatures increase the baby’s muscular activity and awareness.

    Water babies are slow to start breathing due to the delay in stimulation of the trigeminal nerve receptors in the face and around the nose and mouth. You must consider the birth of the baby from the time it leaves the water, not from the delivery of the baby into the water. German midwife, Cornelia Enning, states that babies are more vigorous at a temperature around 92-95 degrees Fahrenheit. If the mother is comfortable in the water, the temperature is OK for baby with only one restrictive parameter – NEVER higher than 100 degrees Fahrenheit.

  • Placental delivery in water

    There is no reason not to allow the birth of the placenta in water. Objections include inability to judge blood loss, possible water embolism and inability to contain all the by products of conception in one place. Evidence now shows that delivery of the placenta is safe, blood loss can be estimated by color evaluation and determination of where the bleeding is arising and there is absolutely no scientific basis for worry over water embolism. Placenta and pieces can be placed in a floating bowl in the water without difficulty. Cutting and clamping of the cord is not recommended with the delivery of the placenta in the water.

    Helpful reminders for the use of water immersion for labor and birth

  • Midwives should discuss the potential advantages and disadvantages of water immersion for labor and birth with each woman prior to labor.
  • The fetal heart should be monitored according to accepted guidelines. Use of a waterproof Doppler is recommended.
  • The woman should be encouraged to maintain adequate hydration and leave the pool to urinate at regular intervals.
  • The woman should be asked to leave the water if there are any concerns about her or her baby’s well being.
  • The water should be kept as clean as possible. Stool and blood clots should be removed from the pool immediately. The pool should be drained, cleaned and refilled if contaminants cannot be easily removed.
  • A small amount of blood often looks like a lot. Undisturbed blood in a pool often congeals at the bottom of the pool into a small clot.
  • The pool or tub should be deep enough for the mother to assume any position comfortably.
  • Encourage mother to help guide her own baby out.
  • Suturing may need to be delayed due to water saturation of tissues.
  • The baby should be born completely underwater with no air contact until the head is brought to the surface, as air and temperature change may stimulate breathing and lead to water aspiration. If a change in position during delivery causes the baby to come in contact with air, the birth should be finished in the air.
  • Care should be taken to avoid undue traction on the cord. There have been reports of cord tearing.
  • The warm water helps maintain the newborn’s temperature to prevent hypothermia. Keep baby submerged with head out only for best heat conservation. Next to mother is best.
  • Encourage breast contact immediately, but breastfeeding is not always possible in the water, especially due to water high water levels.
  • You can insert a footstool or other object (husband) to raise a mother up high enough after the birth.
  • Birth pools should be cleaned completely between uses with a chlorine-releasing agent. All pumps and hoses should also be rinsed with bleach.
  • Outdoor hot tubs are OK to use for labor and birth, if they are cleaned and maintained prior to the labor.
  • Jetted pools are ok to use if they are cleaned properly between patient use.
  • Small amounts of chlorine or bromine are not harmful to mothers or babiesAs when caring for any mother or newborn, the midwife is responsible for using her clinical judgment, responding appropriately to problems that may arise, and for documenting her actions.

    References

    Alderdice, R; Renfrew, M; & Marchant, S (1995) Labor and birth in water in England and Wales: Survey report. British Journal of Midwifery, 3. p 375 – 382.

    Balaskas, J (2004) The Water Birth Book. London: Thorsons.

    Beake, S. (1999) Water birth: a literature review. MIDIRS Midwifery Digest Vol 9 pp 473-477

    Burns, E. (2001) Waterbirth, MIDIRS Midwifery Digest, Supplement 2, S10 – S13.

    Burns, E & Kitzinger, S (2000) Midwifery Guidelines for Use of Water in Labor, Oxford Brookes University: Oxford.

    Eckert, K; Turnbull, D; MacLennan, A. (2001) Immersion in water in the first stage of labor; A randomized controlled trial. Birth, 28 (2) p 84-93.

    Enkin, Keirse, Neilson, Crowther, Duley, Hodnett and Hofmeyr (Eds) (2000) Control of Pain in Labour, in A Guide to Effective Care in Pregnancy and Childbirth Third Edition, Oxford University Press: Oxford.

    Enning, C. (2003). Waterbirth Midwifery: A training book. Hippokrates, Stuttgart, Germany

    Eriksson, M. Mattsson, L. Ladfors, L (1997 Sept) Early or late bath during the first stage of labour: a randomised study of 200 women. Midwifery, vol. 13 No 3 pp. 146-148

    Garland, D., Jones, K. (June, 1997). Waterbirth: updaing the evidence. British Journal of Midwifery Vol 5. No 6,368-373

    Garland, D. (Dec. 2002). Collaborative Waterbirth audit – “Supporting Practice with audit” MIDIRS Midwifery Digest, Vol 12, No 4, Dec 2002, pp 508-511

    Garland, D., Crook, S. (March 2004) Is the use of water in labour an option for women following a previous LSCS. MIDIRS Midwifery Digest Vol 14, No 1 pp 63-67

    Geissbuehler, V., Eberhard, J., (2000) Waterbirths: A comparative study, a prospective study on more than 2000 waterbirths. Fetal Diagnosis and Therapy Sept-Oct; 15(5):291-300

    Geissbuehler, V., Eberhard, J., Lebrecht, A., (2002) Waterbirth: Water temperature and bathing time – mother knows best! Journal of Perinatal Medicine 30(2002) 371-378

    Gilbert RE & Tookey PA (1999) Perinatal mortality and morbidity among babies delivered in water: Surveillance study and postal survey. British Medical Journal, 319(7208) p483-487.

    Harper, B (Summer 2000) Waterbirth Basics: from newborn breathing to hospital protocols. Midwifery Today, 54: 9-15, 68

    Harper, B (Dec 2002) Taking the plunge: reevaluating water temperature. MIDIRS Midwifery Digest, Vol 12, No 4, Dec 2002, pp 506-508

    Johnson, Paul. (1996). Birth under water-—to breathe or not to breathe. British Journal of Obstetrics and Gynaecology, 103: 202-208.

    Lenstrup, C., Schantz, A., Berget, A., Feder, A., Roseno, H. (1987) Warm tub bath during delivery. Acta Obstetrical Gynecology Scandinavia, 66, 709-12.

    Mackey, M. (2001), Use of Water in Labor and Birth, Clinical Obstetrics and Gynecology, Vol 44, No 4, pp 733-749

    Nikodem, VC Immersion in water in pregnancy, labour and birth. (Cochrane Review). In the Cochrane Library, issue 4, 2002. Oxford: Update Software

    Odent, M (1998 March) Use of water during labour – updated recommendations MIDIRS Midwifery Digest, Vol 8, No 1 pp 68-69

    Rush, J, Burlock, S. Lambert K (1996) The effect of whirlpool baths in labour: A randomized controlled trial. Birth, 23, p. 136-143.

    Waldenstrom U & Nilsson C. (1992) Warm tub bath after spontaneous rupture of the membranes. Birth, 19 p 57-62

    Waterbirth International (2004) unpublished Waterbirth Parent Survey, a retrospective analysis of over 3000 births in water.

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.

References

  1. Department of Health. NHS maternity statistics, England 1989/90 to 1994/95. Statistical Bulletin No 28. London: Stationery Office, 1997: 1-16.
  2. Johanson R, Newburn M, MacFarlane A. Has the medicalisation of childbirth gone too far? BMJ 2002;324: 892-5.
  3. Impey L, Boylan P. Active management of labour revisited. Br J Obstet Gynaecol 1999;106: 183-7.
  4. Cammu H, Van Eeckhout E. A randomised controlled trial of early versus delayed use of amniotomy and oxytocin infusion in nulliparous labour. Br J Obstet Gynaecol 1996;103: 313-8.
  5. Sadler LC, Davison T, McCowen LME. A randomised controlled trial and meta analysis of active management of labour. Br J Obstet Gynaecol 2000;107: 909-15.
  6. World Health Organisation maternal health and safe motherhood programme. World Health Organisation partograph in the management of labour. Lancet 1994;343: 1399-404.
  7. Blanch G, Lavender T, Walkinshaw S, Alfirevic A. Dysfunctional labour: a randomised trial. Br J Obstet Gynaecol 1998;105: 117-20.
  8. Lavender T, Walkinson S, Walton I. A prospective study of women’s views of factors contributing to a positive birth experience Midwifery 1999;15: 40-6.
  9. Hodnett ED. Support from caregivers during childbirth. (Cochrane review) In: Cochrane Library. Issue 1. Oxford: Update Software, 2003.

   10. Brownridge P. The nature and consequence of childbirth pain. Eur J Obstet   Gynecol Reprod Biol 1995;32(suppl): S9-15.

  1. De Punzio C, Neri E, Metelli P, Bianchi MS, Venticinqui M, Ferdeghini M, et al. The relationship between maternal relaxation and plasma beta endorphin levels during parturition. J Psychosom Obstet Gynaecol 1994;15: 205-10.
  2. Garland D, Jones K. Waterbirth, first stage immersion or non immersion? Br J Midwifery 1994;2(3): 113-20.
  3. Nikodem VC. Immersion in water during pregnancy, labour and birth. In: Cochrane Library. Issue 1. Oxford: Update Software, 2003.
  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. Alderdice F, Renfrew M, Marchant S, Ashurst H, Hughes P, Berridge G, et al. Labour and birth in water in England and Wales. BMJ 1995;310: 837.

16. Cluett ER, Pickering RM, Brooking JI. An investigation into the feasibility of comparing three management options (augmentation, conservative and water) for nulliparae with dystocia in the first stage of labour. Midwifery 2001;17: 35-43.

17. Altman DG. Confidence intervals for the number needed to treat. BMJ 1998;317: 1309-12. 18. Green JM, Coupland VA, Kitzinger JV. Great expectations. A prospective study of women’s expectations and experiences of childbirth. 2nd ed. Cheshire: Books for Midwives, 1998. 19. Schorn MN, McAllister JL, Blanco JD. Water immersion and the effect on labor. J Nurse Midwifery 1993;38: 336-42.

  1. Rush J, Burlock S, Lambert K, Loasley-Milman M, Hutchinson B, Enkin M. The effects ofwhirlpool baths in labour: a randomised controlled trial. Birth 1996;23: 136-43.
  2. Cammu H, Clasen K, Wettere L, Derde M-P. To bathe or not to bathe during the first stage oflabor. Acta Obstet Gynecol Scand 1994;73: 468-72.
  3. Eckert K, Turnbull D, MacLennan A. Immersion in water in the first stage of labour: arandomised controlled trial. Birth 2001;28: 84-93.
  4. Aird IA, Luckas MJM, Buckett WM, Bousfielf P. Effects intrapartum hydrotherapy on labourparameters. Aust N Z J Obstet Gynaecol 1997;37: 137-42.
  5. Otigbah CM, Dhanjal MK, Harmsworth G. A retrospective comparison of water births and conventional vaginal deliveries. Eur J Obstet Gynecol Reprod Biol 2000;91: 15-20.

25. Ohlsson G, Buchhave P, Leandersson U, Nordstrom L, Rydhstrom H, Sjolin I. Warm tub bathing during labor; maternal and neonatal effects. Acta Obstet Gynecol Scand 2001;80: 311- 4.