Immersion in water during labour and birth

Maternal and neonatal outcomes among spontaneous vaginal births occurring in or out of water following intrapartum water immersion: The POOL cohort study

OBJECTIVE

Warm water immersion during labour provides women with analgesia and comfort. This cohort study aimed to establish among women using intrapartum water immersion analgesia, without antenatal or intrapartum risk factors, whether waterbirth is as safe for them and their babies as leaving the water before birth.

DESIGN

Cohort study with non-inferiority design.

SETTING

Twenty-six UK NHS maternity services.

SAMPLE

A total of 73 229 women without antenatal or intrapartum risk factors, using intrapartum water immersion, between 1 January 2015 and 30 June 2022. The analysis excluded 12 827 (17.5%) women who received obstetric or anaesthetic interventions before birth.

METHODS

Non-inferiority analysis of retrospective and prospective data captured in NHS maternity and neonatal information systems.

MAIN OUTCOME MEASURES

Maternal primary outcome: obstetric anal sphincter injury (OASI) by parity; neonatal composite primary outcome: fetal or neonatal death, neonatal unit admission with respiratory support or administration of antibiotics within 48 hours of birth.

RESULTS

Rates of the primary outcomes were no higher among waterbirths compared with births out of water: rates of OASI among nulliparous women (waterbirth: 730/15 176 [4.8%] versus births out of water: 641/12 210 [5.3%]; adjusted odds ratio [aOR] 0.97, one-sided 95% CI, -∞ to 1.08); rates of OASI among parous women (waterbirth: 269/24 451 [1.1%] versus births out of water 144/8565 [1.7%]; aOR 0.64, one-sided 95% CI -∞ to 0.78) and rates of the composite adverse outcome among babies (waterbirth 263/9868 [2.7%] versus births out of water 224/5078 [4.4%]; aOR 0.65, one-sided 95% CI -∞ to 0.79).

CONCLUSION

Among women using water immersion during labour, remaining in the pool and giving birth in water was not associated with an increase in the incidence of adverse primary maternal or neonatal outcomes.

Introducing waterbirth in a university hospital setting in Sweden: A qualitative study of midwives' experiences

INTRODUCTION

Waterbirth is a popular and increasing care option in several countries but is still debated. In Sweden, there are challenges in the process of reintroducing waterbirth after decades of interruption invoked by a dissuasion. The aim of this study was to explore factors affecting midwives' provision of waterbirth at a university birthing clinic in Sweden.

METHODS

A qualitative research design was used with three focus group interviews with 18 midwives at three birthing units. The data were analyzed using the principles of inductive content analysis.

RESULTS

The midwives in the study expressed positive attitudes and potentiality about waterbirth, contributing to their desire to support physiological birth. However, obstacles were also disclosed, maiming waterbirth evolvement. Hence, two categories emerged, promoting factors and obstructing factors. The subcategories were: Provides a good experience whilst promoting physiological birth; Increased knowledge and information about waterbirth; Support from management; Updated guidelines; Ergonomic challenges; Lacking practical conditions; Lack of knowledge; Paradigm conflicts; and Limiting guidelines.

CONCLUSIONS

The study concluded that midwives recognized both promoting and obstructing factors affecting the provision of waterbirth. The predominant factor highlighted was the care-culture, with a clear distinction between a risk-focused, medicalized approach that inhibits waterbirth and a salutogenic perspective advocating for it. This dichotomy underscores the importance of providing opportunities that support women's choices to facilitate an empowering birth experience.

Insights of healthcare professionals regarding waterbirths and water immersion during labour: A mixed studies review

AIM

To consolidate healthcare professionals' insights about waterbirths and water immersion during labour.

DESIGN

Mixed studies review.

DATA SOURCES

Seven electronic databases were searched from their inception dates till June 2023: PubMed, Embase, CINAHL, PsycINFO, Web of Science, Scopus, ProQuest Dissertations and Theses Global.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines and Pluye and Hong's mixed studies review framework guided this review. The quality of included studies was evaluated using the Mixed Methods Appraisal Tool. Findings were synthesized using the convergent qualitative synthesis method, and results were thematically analysed using Braun and Clarke's framework.

RESULTS

Three main themes were identified from the 22 included studies: (1) believing in waterbirths, (2) opposing forces and (3) plotting the course ahead.

CONCLUSION

Healthcare professionals reported different views about waterbirths and water immersion practices; midwives were most likely to support these practices, followed by nurses and lastly, few physicians supported them. Reasons for opposing waterbirths include insufficient training and support from colleagues as well as concerns about work efficiency, waterbirth safety and litigation issues.

IMPACT

The available evidence suggests the need to provide waterbirth training for healthcare professionals, equip healthcare facilities with necessary waterbirth-related infrastructure and develop appropriate waterbirth policies/guidelines. Healthcare professionals could also consider providing antenatal waterbirth education to women and obtain women's feedback to improve current policies/guidelines. Future research should explore the views of different types of healthcare professionals from more diverse cultures.

REPORTING METHOD

The PRISMA guidelines.

NO PATIENT OR PUBLIC CONTRIBUTION

Systematic review.

Effects of Hydrotherapy on the Management of Childbirth and Its Outcomes-A Retrospective Cohort Study

The use of hydrotherapy during childbirth has gained relevance due to the demand for natural childbirth and greater respect for the woman's choice. Studies have shown benefits such as less use of epidural analgesia, increased ability to cope with pain, shorter labor, and a better overall birth experience.

OBJECTIVE

The main objective of this study was to generate further evidence on maternal and birth outcomes associated with the use of hydrotherapy during labor, specifically aiming to describe the effects of water immersion during all stages of labor (first, second, and third) on women.

METHODOLOGY

A retrospective cohort study was carried out on a random sample of women who gave birth at the Costa del Sol Hospital between January 2010 and December 2020. The calculated sample size was 377 women and the data were extracted from their partograms. After data extraction, two groups were formed: one group used hydrotherapy during childbirth (n = 124), while the other group included women who did not use hydrotherapy during the childbirth process (n = 253).

RESULTS

The results highlight significant differences in pain perception, analgesia use, types of labor, and delivery times between the two groups. Women who did not use hydrotherapy reported higher pain perception, with a median (IQR) of 8 (7-9) on a numerical scale, compared to a median (IQR) of 6 (5-7) for the hydrotherapy group. Furthermore, the group without hydrotherapy required epidural analgesia in 40% of cases, while in the hydrotherapy group, it was only necessary in 20%. In terms of the type of delivery, the hydrotherapy group had more spontaneous vaginal deliveries compared to the non-hydrotherapy group, which had more operative vaginal deliveries. The overall duration of labor was longer in the hydrotherapy group, especially in women who arrived at the hospital late in labor.

CONCLUSIONS

Hydrotherapy is associated with a longer time to delivery. Women with a higher pain tolerance tend to opt for hydrotherapy instead of epidural analgesia.

Is water delivery a good idea to prevent obstetric anal sphincter injuries in low risk primiparae? An exploratory study in a Swiss public teaching hospital

OBJECTIVE

Obstetric anal sphincter injuries are feared perineal injuries that are associated with increased pelvic floor disorders. The knowledge of influencing factors as the mode of delivery is therefore important. The aim of this study is to compare the rate of obstetric anal sphincter injuries in primiparae after water and bed deliveries.

STUDY DESIGN

In this retrospective cohort study 3907 primiparae gave birth in water or on a bed in a Swiss teaching hospital. The diagnosis of obstetric anal sphincter injuries was confirmed by a consultant of obstetrics and gynecology and treated by them. The rates of these injuries after water and bed births were compared. Subgroup analysis was performed to detect possible associative factors, such as birth weight, episiotomy, use of oxytocin in first and second stage of labor.

RESULTS

1844 (47.2 %) of the primiparae had a water delivery and 2063 (52.8 %) a bed delivery. 193 (4.94 %) were diagnosed with obstetric anal sphincter injuries, of which 68 (3.7 %) had a water delivery and 125 (6.1 %) a bed delivery, p < 0.001. Subgroup analysis revealed that, in the first and second stage of labor, the rate of obstetric anal sphincter injuries with oxytocin was significantly lower in water than in bed deliveries; p = 0.025, p < 0.017, respectively. The rate of obstetric anal sphincter injuries in the birth weight or episiotomy subgroups did not reach significance.

CONCLUSIONS

In a teaching hospital setting with standardized labor management, primiparae with a water delivery have the lowest risk for obstetric anal sphincter injuries.

The use of hydrotherapy in the first stage of labour: A systematic review and meta-analysis

AIM

To explore the effect of hydrotherapy applied in the first stage of labour on the health of mother and newborn.

METHODS

This systematic review and meta-analysis was carried out by following PRISMA. The studies were obtained by scanning EBSCO, PubMed, Science Direct, Ovid, Web of Science and Scopus electronic databases. Twenty studies published between 2013 and 2023 were included.

RESULTS

The total sample size of the studies was 8254 (hydrotherapy: 2953, control: 5301). Meta-analyses showed that the perception of pain decreased, comfort level and vaginal birth rate were higher and assisted vaginal birth rate and APGAR scores in the first minute were lower in women who underwent hydrotherapy. There was no difference between groups in terms of the duration of the first and second stage of labour, episiotomy, perineal trauma, intrapartum and postpartum bleeding amounts, use of pain medication and labour augmentations, APGAR scores in the fifth minute, positive neonatal bacterial culture and neonatal intensive care unit need.

CONCLUSION

This study revealed that the results that hydrotherapy decreased the perception of pain and assisted birth, increased the rate of vaginal birth and comfort level and did not adversely affect the health of the mother and baby during the birth process.

Effect of audio-visual therapy on pain and anxiety in labor: A randomized controlled trial

Background

Birth pain affects women at a physical and psychological level. Pain is subjective, and perception will vary among individuals depending on their health status, pain tolerance, and psychological state. Labor pain can drastically affect the birth process and delivery outcomes if not managed well, ranging from poor maternal satisfaction and impaired maternal-newborn bonding to prolonged labor and fetal distress. Since pharmacological pain relief methods harm the fetus, non-pharmacological pain relief methods are gaining popularity among laboring women and healthcare professionals.

Objectives

The study aimed to evaluate the effect of audio-visual therapy on labor pain and maternal anxiety.

Methods

A randomized, controlled, open-label, single-center trial was conducted among 76 primigravida women with no obstetrical complications during the active phase of labor (4-8 cm cervical dilatation). The participants were randomly assigned to an experimental group receiving 50 min of virtual reality intervention or a control group receiving standard care using a computer-generated random sequence. The data related to pain and anxiety were collected using the personal information form, anxiety assessment scale for pregnant women in labor, present behavioral intensity scale, numerical pain rating scale, and post-delivery birth satisfaction checklist.

Results

Groups were homogenous in terms of demographic and obstetric variables. The virtual reality intervention reduced the experimental group's reported pain intensity and anxiety score. However, no statistically significant difference was noted in maternal vital signs and labor and neonatal outcomes between the groups.

Conclusion

The virtual reality intervention reduced labor pain intensity and anxiety among laboring women compared to standard care.

Non-Pharmacological Pain Management in Labor: A Systematic Review

Childbirth is a remarkable, life-changing process and is frequently regarded as an excruciating, physically and emotionally demanding experience that women endure. Labor pain management poses a significant challenge for obstetricians and expectant mothers. Although pharmacological pain management is the gold standard, it still imposes risks on the mother and baby. Recently, non-pharmacological pain management (NPPM) has emerged as a safe, effective option. Six databases were searched for articles published up to 2023 using specific related keywords and defined inclusion and exclusion criteria. The extraction and gathering of data was made so as to be categorized into physical, psychological, and complementary NPPM techniques. In light of the enormous development and diversity of NPPM techniques, the present review aims to examine contemporary NPPM knowledge and application, discussing efficacy, advantages, limitations, and potential adverse effects, with a specific focus on women's individual requirements, to strengthen obstetricians' knowledge in guiding decision-making for women in childbirth.

Understanding the barriers and facilitators related to birthing pool use from organisational and multi-professional perspectives: a mixed-methods systematic review

AIMS

To identify and synthesize the evidence regarding the facilitators and barriers relating to birthing pool use from organizational and multi-professional perspectives.

DESIGN

A systematic integrated mixed methods review was conducted.

DATA SOURCES

MEDLINE, CINAHL, PsychINFO, EMCARE, PROQUEST and Web of Science databases were searched in April 2021, March 2022 and April 2024. We cross-referenced with Google Scholar and undertook reference list searches.

REVIEW METHODS

Data were extracted from studies meeting the inclusion criteria. Barriers and facilitators to birthing pool use were mapped and integrated into descriptive statements further synthesized to develop overarching themes.

RESULTS

Thirty seven articles (29 studies) were included-quantitative (12), qualitative (8), mixed methods (7), and audits (2), from 12 countries. These included the views of 9,082 multi-professionals (midwives, nurses, obstetricians, neonatologists, students, physicians, maternity support workers, doulas and childbirth educators). Additionally, 285 institutional policies or guidelines were included over 9 papers and 1 economic evaluation. Five themes were generated: The paradox of prescriptiveness, The experienced but elusive practitioner, Advocacy and tensions, Trust or Trepidation and It's your choice, but only if it is a choice. These revealed when personal, contextual, and infrastructural factors were aligned and directed towards the support of birth pool use, birthing pool use was a genuine option. Conversely, the more barriers that women and midwives experienced, the less likely it was a viable option, reducing choice and access to safe analgesia.

CONCLUSION

The findings demonstrated a paradoxical reality of water immersion with each of the five themes detailing how the "swing" within these factors directly affected whether birthing pool use was facilitated or inhibited.

Spiritual Experiences of Portuguese Women Who had a Water Birth

This study aimed to understand the significance of spirituality to Portuguese women who had a water birth. In-depth interviews, using a semi-structured questionnaire, were conducted with 24 women who experienced water birth at the hospital or home. Results were analyzed from a narrative interpretation perspective. Three spirituality-related categories emerged: (1) Beliefs and connections with the body; (2) Spirituality: integration of being a woman and transformation during birth; and (3) Spirituality as wisdom, intuition, or the sixth sense. Spirituality was perceived in women's faith and beliefs in a superior being that helped them manage the unpredictability and uncontrollability of giving birth.

Experiences of water immersion during childbirth: a qualitative thematic synthesis

BACKGROUND

The increasing demand for childbirth care based on physiological principles has led official bodies to encourage health centers to provide evidence-based care aimed at promoting women's participation in informed decision-making and avoiding excessive medical intervention during childbirth. One of the goals is to reduce pain and find alternative measures to epidural anesthesia to enhance women's autonomy and well-being during childbirth. Currently, water immersion is used as a non-pharmacological method for pain relief. This review aimed to identify and synthesize evidence on women's and midwives' experiences, values, and preferences regarding water immersion during childbirth.

METHODS

A systematic review and thematic synthesis of qualitative evidence were conducted. Databases were searched and references were checked according to specific criteria. Studies that used qualitative data collection and analysis methods to examine the opinions of women or midwives in the hospital setting were included. Non-qualitative studies, mixed-methods studies that did not separately report qualitative results, and studies in languages other than English or Spanish were excluded. The Critical Appraisal Skills Program Qualitative Research Checklist was used to assess study quality, and results were synthesized using thematic synthesis.

RESULTS

Thirteen studies met the inclusion criteria and were included in this review. The qualitative studies yielded three key themes: 1) reasons identified by women and midwives for choosing a water birth, 2) benefits experienced in water births, and 3) barriers and facilitators of water immersion during childbirth.

CONCLUSIONS

The evidence from qualitative studies indicates that women report benefits associated with water birth. From the perspective of midwives, ensuring safe water births requires adequate resources, midwives training, and rigorous standardized protocols to ensure that all pregnant women can safely opt for water immersion during childbirth with satisfactory results.

An International Continence Society (ICS)/ International Urogynecological Association (IUGA) joint report on the terminology for the assessment and management of obstetric pelvic floor disorders

AIMS

The terminology of obstetric pelvic floor disorders should be defined and reported as part of a wider clinically oriented consensus.

METHODS

This Report combines the input of members of two International Organizations, the International Continence Society (ICS) and the International Urogynecological Association (IUGA). The process was supported by external referees. Appropriate clinical categories and a sub-classification were developed to give coding to definitions. An extensive process of 12 main rounds of internal and 2 rounds of external review was involved to exhaustively examine each definition, with decision-making by consensus.

RESULTS

A terminology report for obstetric pelvic floor disorders, encompassing 357 separate definitions, has been developed. It is clinically-based with the most common diagnoses defined. Clarity and user-friendliness have been key aims to make it usable by different specialty groups and disciplines involved in the study and management of pregnancy, childbirth and female pelvic floor disorders. Clinical assessment, investigations, diagnosis, conservative and surgical treatments are major components. Illustrations have been included to supplement and clarify the text. Emerging concepts, in use in the literature and offering further research potential but requiring further validation, have been included as an Appendix. As with similar reports, interval (5-10 year) review is anticipated to maintain relevance of the document and ensure it remains as widely applicable as possible.

CONCLUSION

A consensus-based Terminology Report for obstetric pelvic floor disorders has been produced to support clinical practice and research.

Dexmedetomidine Combined with Low-Dose Norepinephrine Continuous Pumping to Prevent Hypotension after Cesaresan Section: A Randomized Controlled Trial

Objective

The aim of the study is to explore the clinical effect of dexmedetomidine combined with low-dose norepinephrine (NE) continuous pumping in preventing supine hypotension.

Methods

A total of 160 puerperaes who underwent elective cesarean section were selected. The puerperaes were equally divided into S group (saline), D group (dexmedetomidine), N group (norepinephrine), and DN group (dexmedetomidine combined with norepinephrine) by a random number table method. Apgar scores and umbilical cord venous blood gas values were recorded at 1 and 5 minutes.

Results

There were no statistically significant differences in the age, gestational age, body mass index, bleeding volume, fluid supplement volume, Apgar scores of new borns at the 1st and 5th minute, the blood gas values of umbilical cord arterial and venous in the four groups (P > 0.05). Compared with the S group, the incidence of supine hypotension, the number of NE supplements, the supplementary doses of NE, and the incidence of adverse reactions were significantly reduced in the D, N, and DN groups after spinal anesthesia (P < 0.05). Compared with group D, the incidence of supine hypotension, the number of additional NE, additional dose of NE, and the incidence of adverse reactions in the DN group after spinal anesthesia were significantly reduced (P < 0.05). Compared with the N group, the incidence of supine hypotension, the number of additional NE, the additional dose of NE, and the incidence of adverse reactions in the DN group after spinal anesthesia were significantly reduced (P < 0.05).

Conclusion

Dexmedetomidine combined with continuous pumping of low-dose norepinephrine can effectively prevent the occurrence of supine hypotension, reduce the occurrence of other adverse reactions, and have no obvious adverse effects on neonates. Registration. Chinese Clinical Trial Registry (https://www.chictr.org.cn/enIndex.aspx; ChiCTR2000040979).

Vaginal Birth at Term - Part 2. Guideline of the DGGG, OEGGG and SGGG (S3-Level, AWMF Registry No. 015/083, December 2020)

Purpose This guideline aims to summarize the current state of knowledge about vaginal birth at term. The guideline focuses on definitions of the physiological stages of labor as well as differentiating between various pathological developments and conditions. It also assesses the need for intervention and the options to avoid interventions. The second part of this guideline presents recommendations and statements on care during the dilation and expulsion stages as well as during the placental/postnatal stage. Methods The German recommendations largely reproduce the recommendations of the National Institute for Health and Care Excellence (NICE) CG190 guideline "Intrapartum care for healthy women and babies". Other international guidelines were also consulted in individual cases when compiling this guideline. In addition, a systematic search and analysis of the literature was carried out using PICO questions where necessary, and other systematic reviews and individual studies were taken into account. For easier comprehension, the assessment tools of the Scottish Intercollegiate Guidelines Network (SIGN) were used to evaluate the quality of additionally consulted studies. Otherwise, the GRADE system was used for the NICE guideline, and the evidence reports of the IQWiG were used to evaluate the quality of the evidence. Recommendations Recommendations and statements were formulated based on identified evidence and/or a structured consensus.

Episiotomy Practice and Its Associated Factors in Africa: A Systematic Review and Meta-Analysis

Background

Episiotomy, a surgical procedure that enlarges the vaginal opening during childbirth, was common practice until the early 2000s. Other sources, including the World Health Organization (WHO), advocate for the selective use of episiotomy. Episiotomy rates, on the other hand, have remained high in developing countries, while declining in developed countries. As a result, the current study sought to determine the overall prevalence of episiotomy in Africa as well as the risk factors associated with its practice.

Methods

Articles were searched in international electronic databases. A standardized Microsoft Excel spreadsheet and STATA software version 14 were used for data extraction and analysis, respectively. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) checklist was used to write this report. A random-effects meta-analysis model was used to determine the pooled prevalence of episiotomy. A heterogeneity test was conducted using I-Squared (I²) statistics. Egger's test and funnel plots were conducted to detect publication bias. Subgroup analysis was also conducted. Association was expressed through a pooled odds ratio (OR) with a 95% Confidence Interval (CI).

Result

A total of 21 studies with 40,831 participants were included in the systematic review and meta-analysis. The pooled prevalence of episiotomy practice was 41.7% [95% CI (36.0–47.4), I² = 99.3%, P < 0.001). Primiparity [OR: 6.796 (95% CI (4.862–9.498)), P < 0.001, I²: 95.1%], medical doctors- assisted delivery [OR: 3.675 (95% CI (2.034–6.640)), P < 0.001, I²: 72.6%], prolonged second stage of labor [OR: 5.539 (95% CI (4.252–7.199)), P < 0.001, I²: 0.0%], using oxytocin [OR: 4.207 (95% CI (3.100–5.709)), P < 0.001, I²: 0.0%], instrument -assisted vaginal delivery [OR: 5.578 (95% CI (4.285–7.260)), P < 0.001, I²: 65.1%], and macrosomia [OR: 5.32 (95% CI (2.738–10.339)), P < 0.001, I²: 95.1%] were factors associated with episiotomy practice.

Conclusion

In this review, the prevalence of episiotomy among African parturients was high. A selective episiotomy practice should be implemented to reduce the high episiotomy rates.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021293382, identifier: CRD42021293382.

Pregnant women’s knowledge of non-pharmacological techniques for pain relief during childbirth

INTRODUCTION

The objective of the study was to assess knowledge of pregnant women in the third trimester of pregnancy on non-pharmacological techniques for pain relief during labor and childbirth.

METHODS

A cross-sectional study was conducted at a tertiary care facility of the University of Campinas, Brazil. The participants were 171 pregnant women, aged 18–35 years with 36 or more weeks of a singleton pregnancy. Participants responded to a questionnaire with data about sociodemographic and obstetric characteristics, knowledge on non-pharmacological techniques for pain relief during childbirth, the source of the information on these techniques, practice of physical activity and occurrence of pain during pregnancy. Parous women responded on the use of non-pharmacological techniques for pain relief during childbirth in previous deliveries. Multiple regression analysis with stepwise criteria of selection of variables was used to identify variables significantly associated with knowledge of non-pharmacological techniques for pain relief during childbirth.

RESULTS

A total of 165 (96.5%) participants reported knowledge on at least one non-pharmacological technique; 87.1% on the use of a warm shower during labor for pain relief, 80.7% on the use of the birthing ball, and 74.8% on breathing techniques. There were no significant differences between nulliparous and parous women. The main source of information reported was the Internet. Multivariate analysis showed that pregnant women who had pain during pregnancy reported more knowledge on the use of warm showers during labor (OR=2.64; 95% CI: 1.03–6.73).

CONCLUSIONS

Most women had knowledge of at least one non-pharmacological technique for pain relief during childbirth.

Waterbirth: current knowledge and medico-legal issues

Water immersion during labour and birth has become increasingly popular and widespread in many countries, in particular in midwifery-led care settings. Nevertheless, there is a dearth of quality data about waterbirth, with currently available findings mostly arising from observational studies and case series. The lack of high-quality evidence and the controversial results reported by different studies determined a "behavioral gap" without clearly objective, consistent indications allowing for a sound and evidence-based decision making process. Although water immersion in the first stage of labour is generally considered a safe and cost-effective method of pain management for women in labor, concerns still linger as to the safety of immersion during the second stage of labor and delivery, particularly in terms of neonatal risks and medico-legal implications.

How prospective trial registration can prevent selective outcome reporting and salami slicing?

BACKGROUND

Pre-registration of a clinical trial before the first participant is recruited can help to prevent selective outcome reporting and salami-slicing that can distort the evidence base for an intervention and result in people being offered care or treatment that is not effective. Rates of clinical trial registration in nursing and midwifery are low.

AIM

To use a hypothetical example from midwifery practice to illustrate how selective outcome reporting and salami-slicing can distort the evidence base.

FINDINGS

A trial of immersion in water during labour and birth is used to consider issues in outcome selection and how researchers may be drawn to switch primary outcomes or report different outcomes across multiple papers.

DISCUSSION

In nursing and midwifery science, selective outcome and salami reporting are seemingly common. Prospective trial registration is intended to prevent these practices, enhancing the quality and integrity of the work.

CONCLUSION

Clinical trials are a robust form of primary research evidence and directly impact clinical practice. Researchers must ensure their trials are correctly registered and editors need to reconcile submitted papers and registration entries as part of the review process.

Sexuality and childbirth: a qualitative analysis of women who had a waterbirth

Waterbirth is associated with a less painful childbirth, enhanced couples' intimacy, and positive feelings toward women's bodies and sexuality. In a qualitative, descriptive case study involving 21 participants, we examined the sexual experiences-during childbirth and postpartum-of women who had a waterbirth in a hospital environment. Women discussed their sexuality in the intrapartum and postpartum period after having a waterbirth in public or private hospitals. Two main themes were developed from the data analysis: 'women's sexual pleasure during waterbirth' and 'sexuality after childbirth'. Experiences included transcendence during waterbirth, a feeling that it represented a unique experience, and couples' more positive feelings about intimacy. The shared representations of women suggest that waterbirth can be a calming, joyful event for couples. During this process, they felt that it was a loving, shared event. In addition, after childbirth women experienced positive feelings toward their bodies and sexuality (including orgasm), as well as closer intimacy with their partners.

The effects of water immersion and epidural analgesia on cellular immune response, neuroendocrine, and oxidative markers

Background/aim

Water immersion and epidural analgesia are the most preferred pain relief methods during the labor process. Adverse effects related to these methods, impact on the labor, and perception of pain is well studied in the literature. We aimed to investigate the cord blood level of copeptin, total serum oxidant (TOS), antioxidant (TAS), interleukin (IL)-1, IL-6, and oxytocin after the labor with water immersion, epidural analgesia, and vaginal birth without pain relief.

Materials and methods

The study was conducted with 102 healthy pregnant women admitted to the obstetric delivery unit for noncomplicated term birth. Copeptin, oxytocin, TAS, TOS, IL-1, and IL-6 levels of cord blood and obstetric and neonatal results after vaginal birth were compared.

Results

The study included a total of 102 patients (group 1 = 30, group 2 = 30, and group 3 = 42). We found no significant difference between the three groups in terms of BMI, age, gravidity, parity, birth week, birth weight, interventional birth, perineal trauma, breastfeeding, duration of labor, oxytocin, IL-1 and IL-6 levels (p > 0.05). Neonatal intensive care unit (NICU) need, TAS, TOS, and copeptin levels were higher. Apgar scores were lower in the epidural group (p = 0.011, p = 0.036, p = 0.027, p < 0.001, and p < 0.001 respectively).

Conclusion

Epidural analgesia has deteriorated oxidative stress status and lower neonatal Apgar scores with higher NICU administration compared with water birth and vaginal birth without pain relief.

Project20: Does continuity of care and community-based antenatal care improve maternal and neonatal birth outcomes for women with social risk factors? A prospective, observational study

Background

Social factors associated with poor childbirth outcomes and experiences of maternity care include minority ethnicity, poverty, young motherhood, homelessness, difficulty speaking or understanding English, migrant or refugee status, domestic violence, mental illness and substance abuse. It is not known what specific aspects of maternity care work to improve the maternal and neonatal outcomes for these under-served, complex populations.

Methods

This study aimed to compare maternal and neonatal clinical birth outcomes for women with social risk factors accessing different models of maternity care. Quantitative data on pregnancy and birth outcome measures for 1000 women accessing standard care, group practice and specialist models of care at two large, inner-city maternity services were prospectively collected and analysed using multinominal regression. The level of continuity of care and place of antenatal care were used as independent variables to explore these potentially influential aspects of care. Outcomes adjusted for women’s social and medical risk factors and the service attended.

Results

Women who received standard maternity care were significantly less likely to use water for pain relief in labour (RR 0.11, CI 0.02–0.62) and have skin to skin contact with their baby shortly after birth (RR 0.34, CI 0.14–0.80) compared to the specialist model of care. Antenatal care based in the hospital setting was associated with a significant increase in preterm birth (RR 2.38, CI 1.32–4.27) and low birth weight (RR 2.31, CI 1.24–4.32), and a decrease in induction of labour (RR 0.65, CI 0.45–0.95) compared to community-based antenatal care, this was despite women’s medical risk factors. A subgroup analysis found that preterm birth was increased further for women with the highest level of social risk accessing hospital-based antenatal care (RR 3.11, CI1.49–6.50), demonstrating the protective nature of community-based antenatal care.

Conclusions

This research highlights how community-based antenatal care, with a focus on continuity of carer reduced health inequalities and improved maternal and neonatal clinical outcomes for women with social risk factors. The findings support the current policy drive to increase continuity of midwife-led care, whilst adding that community-based care may further improve outcomes for women at increased risk of health inequalities. The relationship between community-based models of care and neonatal outcomes require further testing in future research. The identification of specific mechanisms such as help-seeking and reduced anxiety, to explain these findings are explored in a wider evaluation.

Waterbirth: a national retrospective cohort study of factors associated with its use among women in England

Background

Waterbirth is widely available in English maternity settings for women who are not at increased risk of complications during labour. Immersion in water during labour is associated with a number of maternal benefits. However for birth in water the situation is less clear, with conclusive evidence on safety lacking and little known about the characteristics of women who give birth in water.

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

Methods

Data were obtained from three population level electronic datasets linked together for the purposes of a national audit of maternity care. The study cohort included women who had no risk factors requiring them to give birth in an obstetric unit according to national guidelines. Multivariate logistic regression models were used to examine maternal (postpartum haemorrhage of 1500mls or more, obstetric anal sphincter injury (OASI)) and neonatal (Apgar score less than 7, neonatal unit admission) outcomes associated with waterbirth.

Results

46,088 low and intermediate risk singleton term spontaneous vaginal births in 35 NHS Trusts in England were included in the analysis cohort. Of these 6264 (13.6%) were recorded as having occurred in water. Waterbirth was more likely in older women up to the age of 40 (adjusted odds ratio (adjOR) for age group 35–39 1.27, 95% confidence interval (1.15,1.41)) and less common in women under 25 (adjOR 18–24 0.76 (0.70, 0.82)), those of higher parity (parity ≥3 adjOR 0.56 (0.47,0.66)) or who were obese (BMI 30–34.9 adjOR 0.77 (0.70,0.85)). Waterbirth was also less likely in black (adjOR 0.42 (0.36, 0.51)) and Asian (adjOR 0.26 (0.23,0.30)) women and in those from areas of increased socioeconomic deprivation (most affluent versus least affluent areas adjOR 0.47 (0.43, 0.52)).

There was no association between delivery in water and low Apgar score (adjOR 0.95 (0.66,1.36)) or incidence of OASI (adjOR 1.00 (0.86,1.16)). There was an association between waterbirth and reduced incidence of postpartum haemorrhage (adjOR 0.68 (0.51,0.90)) and neonatal unit admission (adjOR 0.65 (0.53,0.78)).

Conclusions

In this large observational cohort study, there was no association between waterbirth and specific adverse outcomes for either the mother or the baby. There was evidence that white women from higher socioeconomic backgrounds were more likely to be recorded as giving birth in water. Maternity services should focus on ensuring equitable access to waterbirth.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03724-6.

The Effects of Water Immersion during First Stage of Labor on Postpartum Systemic Inflammatory Response

OBJECTIVE

The systemic inflammatory response is a cascade of physiologic reactions that arise in response to trauma, infection, burn, or any kind of injury. This study aimed to determine the effects of water immersion during the first stage of labor on the systemic inflammatory indices in the postpartum period.

MATERIALS AND METHODS

In this retrospective study, 125 healthy multiparous women with uncomplicated pregnancies between 37 and 41 weeks of gestation who elected for immersion in water during the first stage of labor were compared with multiparous uncomplicated term women who had conventional vaginal births on land (n=125). Age, parity, body mass index (BMI), gestational age, duration of labor, birth weight, Apgar scores, neonatal intensive care unit admissions, and ante- and postpartum whole blood parameters were noted. Antepartum and postpartum neutrophil-to-lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR), platelet-to-lymphocyte ratio (PLR), and mean platelet volume (MPV) were calculated for all patients as systemic inflammatory indices.

RESULTS

Demographic characteristics and birth outcomes of both groups were similar except BMI, which was statistically significantly higher in the water immersion group. There were no statistical differences in antepartum NLR, MLR, PLR, and MPV between the 2 groups. However, postpartum NLR, MLR, PLR, and MPV were statistically significantly lower in the water immersion group compared to the controls.

CONCLUSION

Water immersion during the first stage of labor might decrease systemic inflammatory indices in the early postpartum period.

Establishing the safety of waterbirth for mothers and babies: a cohort study with nested qualitative component: the protocol for the POOL study

INTRODUCTION

Approximately 60 000 (9/100) infants are born into water annually in the UK and this is likely to increase. Case reports identified infants with water inhalation or sepsis following birth in water and there is a concern that women giving birth in water may sustain more complex perineal trauma. There have not been studies large enough to show whether waterbirth increases these poor outcomes. The POOL Study (ISRCTN13315580) plans to answer the question about the safety of waterbirths among women who are classified appropriate for midwifery-led intrapartum care.

METHODS AND ANALYSIS

A cohort study with a nested qualitative component. Objectives will be answered using retrospective and prospective data captured in electronic National Health Service (NHS) maternity and neonatal systems. The qualitative component aims to explore factors influencing pool use and waterbirth; data will be gathered via discussion groups, interviews and case studies of maternity units.

ETHICS AND DISSEMINATION

The protocol has been approved by NHS Wales Research Ethics Committee (18/WA/0291) the transfer of identifiable data has been approved by Health Research Authority Confidentiality Advisory Group (18CAG0153).Study findings and innovative methodology will be disseminated through peer-reviewed journals, conferences and events. Results will be of interest to the general public, clinical and policy stakeholders in the UK and will be disseminated accordingly.

Prospective cohort study of water immersion for labour and birth compared with standard care in an Irish maternity setting

OBJECTIVE

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

DESIGN

Prospective cohort study.

SETTING

Maternity hospital, Ireland, 2016-2019.

PARTICIPANTS

A cohort of 190 low-risk women who used water immersion; 100 gave birth in water and 90 laboured only in water. A control group of 190 low-risk women who received standard care.

METHODS

Logistic regression analyses examined associations between water immersion and birth outcomes adjusting for confounders. A validated Childbirth Experience Questionnaire was completed.

MAIN OUTCOME MEASURES

Perineal tears, obstetric anal sphincter injuries (OASI), postpartum haemorrhage (PPH), neonatal unit admissions (NNU), breastfeeding and birth experiences.

RESULTS

Compared with standard care, women who chose water immersion had no significant difference in perineal tears (71.4% vs 71.4%, adj OR 0.83; 95% CI 0.49 to 1.39) or in OASI (3.3% vs 3.8%, adj OR 0.91; 0.26-2.97). Women who chose water immersion were more likely to have a PPH ≥500 mL (10.5% vs 3.7%, adj OR 2.60; 95% CI 1.03 to 6.57), and to exclusively breastfeed at discharge (71.1% vs 45.8%, adj OR 2.59; 95% CI 1.66 to 4.05). There was no significant difference in NNU admissions (3.7% vs 3.2%, adj OR 1.06; 95% CI 0.33 to 3.42). Women who gave birth in water were no more likely than women who used water for labour only to require perineal suturing (64% vs 80.5%, adj OR 0.63; 95% CI 0.30 to 1.33), to experience OASI (3.0% vs 3.7%, adj OR 1.41; 95% CI 0.23 to 8.79) or PPH (8.0% vs 13.3%, adj OR 0.73; 95% CI 0.26 to 2.09). Women using water immersion reported more positive memories than women receiving standard care (p<0.01).

CONCLUSIONS

Women choosing water immersion for labour or birth were no more likely to experience adverse birth outcomes than women receiving standard care and rated their birth experiences more highly.

Factors influencing water immersion during labour: qualitative case studies of six maternity units in the United Kingdom

BACKGROUND

Water immersion during labour can provide benefits including reduced need for regional analgesia and a shorter labour. However, in the United Kingdom a minority of women use a pool for labour or birth, with pool use particularly uncommon in obstetric-led settings. Maternity unit culture has been identified as an important influence on pool use, but this and other possible factors have not been explored in-depth. Therefore, the aim of this study was to identify factors influencing pool use through qualitative case studies of three obstetric units and three midwifery units in the UK.

METHODS

Case study units with a range of waterbirth rates and representing geographically diverse locations were selected. Data collection methods comprised semi-structured interviews, collation of service documentation and public-facing information, and observations of the unit environment. There were 111 interview participants, purposively sampled to include midwives, postnatal women, obstetricians, neonatologists, midwifery support workers and doulas. A framework approach was used to analyse all case study data.

RESULTS

Obstetric unit culture was a key factor restricting pool use. We found substantial differences between obstetric and midwifery units in terms of equipment and resources, staff attitudes and confidence, senior staff support and women's awareness of water immersion. Generic factors influencing use of pools across all units included limited access to waterbirth training, sociodemographic differences in desire for pool use and issues using waterproof fetal monitoring equipment.

CONCLUSIONS

Case study findings provide new insights into the influence of maternity unit culture on waterbirth rates. Access to pool use could be improved through midwives based in obstetric units having more experience of waterbirth, providing obstetricians and neonatologists with information on the practicalities of pool use and improving accessibility of antenatal information. In terms of resources, recommendations include increasing pool provision, ensuring birth room allocation maximises the use of unit resources, and providing pool room environments that are acceptable to midwives.

A Discrete Choice Experiment on Women's Preferences for Water Immersion During Labor and Birth: Identification, Refinement and Selection of Attributes and Levels

Objectives: To identify attributes (i.e., characteristics describing a scenario) and levels (i.e., each characteristic may be defined by a different level) that would be included in a discrete choice experiment (DCE) questionnaire to evaluate women’s preferences for water immersion during labor and birth. Methods: A mixed-method approach, combining systematic reviews of the literature and patient focus groups to identify attributes and levels explaining women’s preferences. After the focus groups, preference exercises were conducted and led to the creation of the questionnaire, including the DCE. A qualitative validation of the questionnaire was conducted with women from the focus groups and with medical experts. Results: The literature reviews provided 26 attributes to be considered for childbirth in water, and focus groups identified 14 additional attributes. From these 40 attributes, preference exercises allowed us to select four for the DCE, in addition to the birth mode. Labor duration was also included, even if it was not well ranked, as it is the main clinical outcome in the literature. Validation with experts and women did not change the choice of attributes but slightly changed the levels selected. The final six attributes were: birth mode, duration of the labor phase, pain sensation, risk of severe tears in the perineum during the expulsion of the newborn, risk of death of the newborn, and general condition of the newborn (Apgar) score at 5 minutes. Conclusion: This study allowed us to detail all the stages for the design of a DCE questionnaire. To date, this is the first study of this kind in the context of women’s preferences for water immersion during labor and birth.

Effect of music on labor and delivery in nulliparous singleton pregnancies: a randomized clinical trial

BACKGROUND

Women's experience of pain during labor varies greatly, and pain control is a major concern for obstetricians. Several methods have been studied for pain management for women in labor, including drug and non-drug interventions.

OBJECTIVE

To test the hypothesis that in nulliparous women with singleton pregnancies at term, listening to music would reduce the pain level during labor.

METHODS

Parallel group non-blinded randomized clinical trial conducted at a single center in Italy. Nulliparous women in spontaneous labor with singleton pregnancies and vertex presentation admitted in labor and delivery room between 37 0/7 and 42 0/7 weeks of gestation for active phase of labor were eligible, and were randomized in a 1:1 ratio to receive music during labor or no music during labor. Music in labor was defined listening to music from the randomization until the delivery of the baby. The primary endpoint was the pain level during the active phase of labor, recorded using the visual analogue scale (VAS) for pain, ranging from 0 (no pain) to 10 (unbearable pain). The effect of music use during labor on each outcome was quantified as the mean difference (MD) with 95% confidence interval (CI).

RESULTS

During the study period, 30 women agree to take part in the study, underwent randomization, and were enrolled and followed up. 15 women were randomized in the music group, and 15 in the control group. No patients were lost to follow up for the primary outcome. Pain level during the active phase of labor was scored 8.8 ± 0.9 in the music group, and 9.8 ± 0.3 in the control group (MD - 1.00 point, 95% CI - 1.48 to - 0.52; P < 0.01). Music during labor and delivery was also associated with a decreased pain at 1 h postpartum (MD - 2.40 points, 95% CI - 4.30 to - 0.50), and decreased anxiety level during active phase of labor (MD - 19.90 points, 95% CI - 38.72 to - 1.08), second stage of labor (MD - 49.40 points, 95% CI - 69.44 to - 29.36), and at 1 h postpartum (MD - 27.00 points, 95% CI - 47.37 to - 6.63).

CONCLUSION

In nulliparous women with singleton pregnancies at term, listening to music reduces the pain level, and the anxiety level during labor.

TRIAL REGISTRATION

Clinicaltrials.gov NCT03779386.

Acupuncture or acupressure for pain management during labour

BACKGROUND

Many women would like to avoid pharmacological or invasive methods of pain management in labour and this may contribute towards the popularity of complementary methods of pain management. This review examined evidence about the use of acupuncture and acupressure for pain management in labour. This is an update of a review last published in 2011.

OBJECTIVES

To examine the effects of acupuncture and acupressure for pain management in labour.

SEARCH METHODS

For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register, (25 February 2019), the Cochrane Central Register of Controlled Trials (the Cochrane Library 2019, Issue 1), MEDLINE (1966 to February 2019), CINAHL (1980 to February 2019), ClinicalTrials.gov (February 2019), the WHO International Clinical Trials Registry Platfory (ICTRP) (February 2019) and reference lists of included studies.

SELECTION CRITERIA

Published and unpublished randomised controlled trials (RCTs) comparing acupuncture or acupressure with placebo, no treatment or other non-pharmacological forms of pain management in labour. We included all women whether nulliparous or multiparous, and in spontaneous or induced labour. We included studies reported in abstract form if there was sufficient information to permit assessment of risk of bias. Trials using a cluster-RCT design were eligible for inclusion, but quasi-RCTs or cross-over studies were not.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. We assessed the certainty of the evidence using the GRADE approach.

MAIN RESULTS

We included 28 trials with data reporting on 3960 women. Thirteen trials reported on acupuncture and 15 trials reported on acupressure. No study was at a low risk of bias on all domains. Pain intensity was generally measured on a visual analogue scale (VAS) of 0 to 10 or 0 to 100 with low scores indicating less pain. Acupuncture versus sham acupuncture Acupuncture may make little or no difference to the intensity of pain felt by women when compared with sham acupuncture (mean difference (MD) -4.42, 95% confidence interval (CI) -12.94 to 4.09, 2 trials, 325 women, low-certainty evidence). Acupuncture may increase satisfaction with pain relief compared to sham acupuncture (risk ratio (RR) 2.38, 95% CI 1.78 to 3.19, 1 trial, 150 women, moderate-certainty evidence), and probably reduces the use of pharmacological analgesia (RR 0.75, 95% CI 0.63 to 0.89, 2 trials, 261 women, moderate-certainty evidence). Acupuncture may have no effect on assisted vaginal birth (very low-certainty evidence), and probably little to no effect on caesarean section (low-certainty evidence). Acupuncture compared to usual care We are uncertain if acupuncture reduces pain intensity compared to usual care because the evidence was found to be very low certainty (standardised mean difference (SMD) -1.31, 95% CI -2.14 to -0.49, 4 trials, 495 women, I² = 93%). Acupuncture may have little to no effect on satisfaction with pain relief (low-certainty evidence). We are uncertain if acupuncture reduces the use of pharmacological analgesia because the evidence was found to be very low certainty (average RR 0.72, 95% CI 0.60 to 0.85, 6 trials, 1059 women, I² = 70%). Acupuncture probably has little to no effect on assisted vaginal birth (low-certainty evidence) or caesarean section (low-certainty evidence). Acupuncture compared to no treatment One trial compared acupuncture to no treatment. We are uncertain if acupuncture reduces pain intensity (MD -1.16, 95% CI -1.51 to -0.81, 163 women, very low-certainty evidence), assisted vaginal birth or caesarean section because the evidence was found to be very low certainty. Acupuncture compared to sterile water injection We are uncertain if acupuncture has any effect on use of pharmacological analgesia, assisted vaginal birth or caesarean section because the evidence was found to be very low certainty. Acupressure compared to a sham control We are uncertain if acupressure reduces pain intensity in labour (MD -1.93, 95% CI -3.31 to -0.55, 6 trials, 472 women) or assisted vaginal birth because the evidence was found to be very low certainty. Acupressure may have little to no effect on use of pharmacological analgesia (low-certainty evidence). Acupressure probably reduces the caesarean section rate (RR 0.44, 95% CI 0.27 to 0.71, 4 trials, 313 women, moderate-certainty evidence). Acupressure compared to usual care We are uncertain if acupressure reduces pain intensity in labour (SMD -1.07, 95% CI -1.45 to -0.69, 8 trials, 620 women) or increases satisfaction with pain relief (MD 1.05, 95% CI 0.75 to 1.35, 1 trial, 105 women) because the evidence was found to be very low certainty. Acupressure may have little to no effect on caesarean section (low-certainty evidence). Acupressure compared to a combined control Acupressure probably slightly reduces the intensity of pain during labour compared with the combined control (measured on a scale of 0 to 10 with low scores indicating less pain) (SMD -0.42, 95% CI -0.65 to -0.18, 2 trials, 322 women, moderate-certainty evidence). We are uncertain if acupressure has any effect on the use of pharmacological analgesia (RR 0.94, 95% CI 0.71 to 1.25, 1 trial, 212 women), satisfaction with childbirth, assisted vaginal birth or caesarean section because the certainty of the evidence was all very low. No studies were found that reported on sense of control in labour and only one reported on satisfaction with the childbirth experience.

AUTHORS' CONCLUSIONS

Acupuncture in comparison to sham acupuncture may increase satisfaction with pain management and reduce use of pharmacological analgesia. Acupressure in comparison to a combined control and usual care may reduce pain intensity. However, for other comparisons of acupuncture and acupressure, we are uncertain about the effects on pain intensity and satisfaction with pain relief due to very low-certainty evidence. Acupuncture may have little to no effect on the rates of caesarean or assisted vaginal birth. Acupressure probably reduces the need for caesarean section in comparison to a sham control. There is a need for further high-quality research that include sham controls and comparisons to usual care and report on the outcomes of sense of control in labour, satisfaction with the childbirth experience or satisfaction with pain relief.

Factors influencing the use of birth pools in the United Kingdom: Perspectives of women, midwives and medical staff

Objective

To identify factors influencing the use of birth pools.

Design

Online discussion groups and semi-structured interviews, analysed thematically.

Setting

United Kingdom.

Participants

85 women and 21 midwives took part in online discussion groups; 14 medical staff participated in interviews.

Findings

Factors influencing the use of birth pools were grouped into three overarching categories: resources, unit culture and guidelines, and staff endorsement. Resources encompassed pool availability, efficiency of pool use and availability of waterproof cardiotocograph equipment. Unit culture and guidelines related to eligibility criteria for pool use, medicalisation of birth and differences between midwifery-led and obstetric-led care. Staff endorsement encompassed attitudes towards pool use.

Key conclusions

Accessibility of birth pools was often limited by eligibility criteria. While midwifery-led units were generally supportive of pool use, obstetric-led units were described as an over-medicalised environment in which pool use was restricted and relied on maternal request.

Implications for practice

Midwives can improve women's access to birth pools by providing information antenatally and proactively offering this as an option in labour. Maternity units should work to implement evidence-based guidelines on pool use, increase pool availability (even where there appears to be low demand), and enhance awareness amongst medical staff of the benefits of water immersion.

Does water birth affect the risk of obstetric anal sphincter injury? Development of a prognostic model

INTRODUCTION AND HYPOTHESIS

Obstetric anal sphincter injury (OASI) is a significant complication of vaginal delivery. Water birth has become a popular preference for women giving birth in the UK, however, there is limited data on the risk of OASI following water birth. Our aim was to assess OASI risk in low-risk women giving birth in water without medical intervention compared with on land and to create a prognostic model for OASI prediction.

METHODS

This was a retrospective study of 15,734 low-risk women giving birth by spontaneous vaginal delivery between January 2008 and October 2014 in a midwifery-led unit (MLU). Patient factors and delivery data were analysed to identify differences between water and land births. Univariate analysis determined factors that statistically predicted OASI and was then used to create multivariate analysis. Significant multivariate factors were used to create a prognostic model to predict likelihood of OASI.

RESULTS

OASI rates were 1.6% on land and 3.3% in water [odds ratio (OR) 2.10, 95% confidence interval (CI) 1.5-2.94). Multivariate analysis confirmed water birth, ethnicity and parity as independent risk factors for OASI (adjusted OR water birth: 1.77 (CI 1.25-2.51). Our prognostic model showed Black and Asian primigravidae following water birth had the highest risk of OASI and white multiparae on land the lowest.

CONCLUSION

This study of comparable low-risk women shows an increased risk of OASI following water birth compared with land birth. Use of this prognostic model will help women determine their risk of OASI following birth in water or on land.

Experiences of Greek women of water immersion during normal labour and birth. A qualitative study

INTRODUCTION

There is scarce information on water births in Greece, as few women labour and give birth in water. The Greek public health system does not provide water immersion as a birthing option, and so women can only experience this option in private healthcare settings. The aim of this study was to explore the key concepts and themes identified from an analysis of the experiences of women who laboured and gave birth immersed in water.

METHODS

This was a qualitative study involving twelve women who used water immersion during labour, of which nine had also a water birth. Individual interviews were conducted and their content was analysed using thematic analysis.

RESULTS

Three main themes were identified: Water use as a natural way of birth, Mixed messages from the healthcare professionals, and Partner's supportive role during water birth. All women reported a positive birth experience and water immersion helped them cope with the pain of labour. They felt greatly empowered following birth and this contributed to successful breastfeeding for more than one year, in the majority of cases. They reported difficulties in finding healthcare professionals that were in support of their choices. The women felt highly supported by the partner's role.

CONCLUSIONS

Labouring and giving birth immersed in water was met with great satisfaction by all women. The findings of this study have added to the current body of midwifery knowledge on how water immersion can improve a woman's experience and so support a normal birth outcome.