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Nikodem VC, Edwards SE, Krzyzanski AM, Berghella V, Hofmeyr GJ. Immersion in water during the second stage of labor: a randomized controlled trial. Am J Obstet Gynecol MFM 2022; 4:100721. [PMID: 35977701 DOI: 10.1016/j.ajogmf.2022.100721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 08/11/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Current obstetrical guidelines in the United States caution firmly against birth in water, but patients remain interested in this intervention. Limited data are available to evaluate the safety and efficacy of water immersion in the second stage of labor for patients and neonates. OBJECTIVE This study aimed to ascertain the effects of water use during the second stage of labor on maternal outcomes. Second, it aimed to propose guidelines for midwives conducting the second stage of labor in water. STUDY DESIGN A randomized, prospective design was used to evaluate the primary outcomes of maternal experience in labor and trauma to the birth canal and several secondary neonatal and maternal outcomes when participants delivered in water vs in a conventional setting. Participants were recruited at 2 academic state hospitals serving the same low- to middle-income group urban population in the midwestern suburbs of Johannesburg, South Africa over a period of 2 years. Individuals in active labor without exclusion criteria were asked to participate in the study. A total of 120 participants were enrolled, with 60 randomized to water birth and 60 to conventional birth. Outcomes were compared using the chi-square and Fisher exact tests. RESULTS The use of water during birth significantly reduced the participants' perception of experienced pain than what they expected it to be (P=.006) and enhanced their satisfaction with their ability to cope with labor (P=.010). No differences were noted in trauma to the birth canal. No adverse maternal effects were noted. One early neonatal death occurred in the water group. The most likely cause of death was preexisting intrauterine fetal infection. CONCLUSION Participants who delivered in water were significantly more satisfied with their birthing experience. The possible harmful effect of inhalation of fresh water by a baby is not resolved, and a large randomized controlled trial is recommended. It is recommended that immersion in water during the second stage of labor should only be offered by competent birth attendants who follow specific guidelines until clear evidence is available on the possible beneficial or harmful effects. Pending further evidence, we recommend adding salt to the bath to produce a physiological saline solution to reduce theoretical risks associated with fresh water inhalation by the neonate.
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Affiliation(s)
| | - Sara E Edwards
- Department of Obstetrics and Gynecology, University of Illinois, Chicago, IL (Dr Edwards).
| | - Annette M Krzyzanski
- School of Osteopathic Medicine, Campbell University, Lillington, NC (Ms Krzyzanski)
| | - Vincenzo Berghella
- Division of Maternal-Fetal Medicine, Thomas Jefferson University, Philadelphia, PA (Dr Berghella)
| | - G Justus Hofmeyr
- University of Botswana, Gaborone, Botswana (Dr Hofmeyr); University of the Witwatersrand, Johannesburg, Johannesburg, South Africa (Dr Hofmeyr); Walter Sisulu University, Mthatha, South Africa (Dr Hofmeyr); University of Fort Hare, Alice, South Africa (Dr Hofmeyr)
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Abstract
BACKGROUND Water immersion during labour and birth is increasingly popular and is becoming widely accepted across many countries, and particularly in midwifery-led care settings. However, there are concerns around neonatal water inhalation, increased requirement for admission to neonatal intensive care unit (NICU), maternal and/or neonatal infection, and obstetric anal sphincter injuries (OASIS). This is an update of a review last published in 2011. OBJECTIVES To assess the effects of water immersion during labour and/or birth (first, second and third stage of labour) on women and their infants. SEARCH METHODS We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) (18 July 2017), and reference lists of retrieved trials. SELECTION CRITERIA We included randomised controlled trials (RCTs) comparing water immersion with no immersion, or other non-pharmacological forms of pain management during labour and/or birth in healthy low-risk women at term gestation with a singleton fetus. Quasi-RCTs and cluster-RCTs were eligible for inclusion but none were identified. Cross-over trials were not eligible for inclusion. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. Two review authors assessed the quality of the evidence using the GRADE approach. MAIN RESULTS This review includes 15 trials conducted between 1990 and 2015 (3663 women): eight involved water immersion during the first stage of labour; two during the second stage only; four during the first and second stages of labour, and one comparing early versus late immersion during the first stage of labour. No trials evaluated different baths/pools, or third-stage labour management. All trials were undertaken in a hospital labour ward setting, with a varying degree of medical intervention considered as routine practice. No study was carried out in a midwifery-led care setting. Most trial authors did not specify the parity of women. Trials were subject to varying degrees of bias: the intervention could not be blinded and there was a lack of information about randomisation, and whether analyses were undertaken by intention-to-treat.Immersion in water versus no immersion (first stage of labour)There is probably little or no difference in spontaneous vaginal birth between immersion and no immersion (82% versus 83%; risk ratio (RR) 1.01, 95% confidence interval (CI) 0.97 to 1.04; 6 trials; 2559 women; moderate-quality evidence); instrumental vaginal birth (14% versus 12%; RR 0.86, 95% CI 0.70 to 1.05; 6 trials; 2559 women; low-quality evidence); and caesarean section (4% versus 5%; RR 1.27, 95% CI 0.91 to 1.79; 7 trials; 2652 women; low-quality evidence). There is insufficient evidence to determine the effect of immersion on estimated blood loss (mean difference (MD) -14.33 mL, 95% CI -63.03 to 34.37; 2 trials; 153 women; very low-quality evidence) and third- or fourth-degree tears (3% versus 3%; RR 1.36, 95% CI 0.85 to 2.18; 4 trials; 2341 women; moderate-quality evidence). There was a small reduction in the risk of using regional analgesia for women allocated to water immersion from 43% to 39% (RR 0.91, 95% CI 0.83 to 0.99; 5 trials; 2439 women; moderate-quality evidence). Perinatal deaths were not reported, and there is insufficient evidence to determine the impact on neonatal intensive care unit (NICU) admissions (6% versus 8%; average RR 1.30, 95% CI 0.42 to 3.97; 2 trials; 1511 infants; I² = 36%; low-quality evidence), or on neonatal infection rates (1% versus 1%; RR 2.00, 95% CI 0.50 to 7.94; 5 trials; 1295 infants; very low-quality evidence).Immersion in water versus no immersion (second stage of labour)There were no clear differences between groups for spontaneous vaginal birth (97% versus 99%; RR 1.02, 95% CI 0.96 to 1.08; 120 women; 1 trial; low-quality evidence); instrumental vaginal birth (2% versus 2%; RR 1.00, 95% CI 0.06 to 15.62; 1 trial; 120 women; very low-quality evidence); caesarean section (2% versus 1%; RR 0.33, 95% CI 0.01 to 8.02; 1 trial; 120 women; very low-quality evidence), and NICU admissions (11% versus 9%; RR 0.78, 95% CI 0.38 to 1.59; 2 trials; 291 women; very low-quality evidence). Use of regional analgesia was not relevant to the second stage of labour. Third- or fourth-degree tears, and estimated blood loss were not reported in either trial. No trial reported neonatal infection but did report neonatal temperature less than 36.2°C at birth (9% versus 9%; RR 0.98, 95% CI 0.30 to 3.20; 1 trial; 109 infants; very low-quality evidence), greater than 37.5°C at birth (6% versus 15%; RR 2.62, 95% CI 0.73 to 9.35; 1 trial; 109 infants; very low-quality evidence), and fever reported in first week (5% versus 2%; RR 0.53, 95% CI 0.10 to 2.82; 1 trial; 171 infants; very low-quality evidence), with no clear effect between groups being observed. One perinatal death occurred in the immersion group in one trial (RR 3.00, 95% CI 0.12 to 72.20; 1 trial; 120 infants; very low-quality evidence). The infant was born to a mother with HIV and the cause of death was deemed to be intrauterine infection.There is no evidence of increased adverse effects to the baby or woman from either the first or second stage of labour.Only one trial (200 women) compared early and late entry into the water and there were insufficient data to show any clear differences. AUTHORS' CONCLUSIONS In healthy women at low risk of complications there is moderate to low-quality evidence that water immersion during the first stage of labour probably has little effect on mode of birth or perineal trauma, but may reduce the use of regional analgesia. The evidence for immersion during the second stage of labour is limited and does not show clear differences on maternal or neonatal outcomes intensive care. There is no evidence of increased adverse effects to the fetus/neonate or woman from labouring or giving birth in water. Available evidence is limited by clinical variability and heterogeneity across trials, and no trial has been conducted in a midwifery-led setting.
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Affiliation(s)
- Elizabeth R Cluett
- University of SouthamptonFaculty of Health SciencesNightingale Building (67)HighfieldSouthamptonHantsUKSO17 1BJ
| | - Ethel Burns
- Faculty of Health and Life Sciences, Oxford Brookes UniversityDepartment of Psychology, Social Work and Public HealthJack Straws LaneOxfordUKOX3 0FL
| | - Anna Cuthbert
- The University of LiverpoolCochrane Pregnancy and Childbirth Group, Department of Women's and Children's HealthFirst Floor, Liverpool Women's NHS Foundation TrustCrown StreetLiverpoolUKL8 7SS
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Cooper M, Warland J, McCutcheon H. Australian midwives views and experiences of practice and politics related to water immersion for labour and birth: A web based survey. Women Birth 2017; 31:184-193. [PMID: 29037484 DOI: 10.1016/j.wombi.2017.09.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Revised: 08/26/2017] [Accepted: 09/01/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND There is little published research that has examined practitioners' views and experiences of pain relieving measures commonly used during labour and birth, particularly for non-pharmacological measures such as water immersion. Furthermore, there is minimal published research examining the process of policy and guideline development, that is, the translation of published research to usable practice guidance. AIMS The aims of phase three of a larger study were to explore midwives knowledge, experiences and support for the option of water immersion for labour and birth in practice and their involvement, if any, in development of policy and guidelines pertaining to the option. METHODS Phase three of a three phased mixed methods study included a web based survey of 234 Australian midwives who had facilitated and/or been involved in the development of policies and/or guidelines relating to the practice of water immersion. FINDINGS Midwives who participated in this study were supportive of both water immersion for labour and birth reiterating documented benefits of reduced pain, maternal relaxation and a positive birth experience. The most significant concerns were maternal collapse, the difficulty of estimating blood loss and postpartum haemorrhage whilst barriers included lack of accredited staff, lifting equipment and negative attitudes. Midwives indicated that policy/guideline documents limited their ability to facilitate water immersion and did not always to support women's informed choice. CONCLUSION Midwives who participated in this study supported the practice of water immersion reiterating the benefits documented in the literature and minimal risk to the woman and baby. ETHICAL CONSIDERATIONS The Human Research Ethics Committee of the University of South Australia approved the research.
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Affiliation(s)
- Megan Cooper
- School of Nursing and Midwifery, University of South Australia, City East Campus, Adelaide, South Australia, Australia.
| | - Jane Warland
- School of Nursing and Midwifery, University of South Australia, City East Campus, Adelaide, South Australia, Australia
| | - Helen McCutcheon
- Faculty of Health and Behavioural Sciences, The University of Queensland, St. Lucia Campus, Brisbane, Queensland, Australia
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Taylor H, Kleine I, Bewley S, Loucaides E, Sutcliffe A. Neonatal outcomes of waterbirth: a systematic review and meta-analysis. Arch Dis Child Fetal Neonatal Ed 2016; 101:F357-65. [PMID: 27127204 DOI: 10.1136/archdischild-2015-309600] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Accepted: 04/04/2016] [Indexed: 11/04/2022]
Abstract
INTRODUCTION In 2015, 9% of babies born in the UK were delivered underwater. Waterbirth is increasing in popularity, despite uncertainty regarding its safety for neonates. This systematic review and meta-analysis appraises the existing evidence for neonatal outcomes following waterbirth. METHODS A structured electronic database search was performed with no language restrictions. All comparative studies which reported neonatal outcomes following waterbirth, and that were published since 1995, were included. Quality appraisal was performed using a modified Critical Appraisal Skills Programme scoring system. The primary outcome was neonatal mortality. Data for each neonatal outcome were tabulated and analysed. Meta-analysis was performed for comparable studies which reported sufficient data. RESULTS The majority of the 29 included studies were small, with limited follow-up and methodological flaws. They were mostly conducted in Europe and high-income countries. Reporting of data was heterogeneous. No significant difference in neonatal mortality, neonatal intensive care unit/special care baby unit admission rate, Apgar scores, umbilical cord gases or infection rates was found between babies delivered into water and on land. CONCLUSIONS This systematic review and meta-analysis did not identify definitive evidence that waterbirth causes harm to neonates compared with land birth. However, there is currently insufficient evidence to conclude that there are no additional risks or benefits for neonates when comparing waterbirth and conventional delivery on land.
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Affiliation(s)
- Henry Taylor
- Population, Policy, and Practice, Institute of Child Health, University College Hospital, London, UK
| | - Ira Kleine
- Obstetrics and Gynaecology, Luton and Dunstable University Hospital Trust, Luton, UK
| | - Susan Bewley
- Women's Health Academic Centre, King's College London, London, UK
| | - Eva Loucaides
- Population, Policy, and Practice, Institute of Child Health, University College Hospital, London, UK
| | - Alastair Sutcliffe
- Population, Policy, and Practice, Institute of Child Health, University College Hospital, London, UK
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Bovbjerg ML, Cheyney M, Everson C. Maternal and Newborn Outcomes Following Waterbirth: The Midwives Alliance of North America Statistics Project, 2004 to 2009 Cohort. J Midwifery Womens Health 2016; 61:11-20. [PMID: 26789485 DOI: 10.1111/jmwh.12394] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Data on the safety of waterbirth in the United States are lacking. METHODS We used data from the Midwives Alliance of North America Statistics Project, birth years 2004 to 2009. We compared outcomes of neonates born underwater waterbirth (n = 6534), neonates not born underwater nonwaterbirth (n = 10,290), and neonates whose mothers intended a waterbirth but did not have one intended waterbirth (n = 1573). Neonatal outcomes included a 5-minute Apgar score of less than 7, neonatal hospital transfer, and hospitalization or neonatal intensive care unit (NICU) admission in the first 6 weeks. Maternal outcomes included genital tract trauma, postpartum hospital transfer, and hospitalization or infection (uterine, endometrial, perineal) in the first 6 weeks. We used logistic regression for all analyses, controlling for primiparity. RESULTS Waterbirth neonates experienced fewer negative outcomes than nonwaterbirth neonates: the adjusted odds ratio (aOR) for hospital transfer was 0.46 (95% confidence interval [CI], 0.32-0.68; P < .001); the aOR for infant hospitalization in the first 6 weeks was 0.75 (95% CI, 0.63-0.88; P < .001); and the aOR for NICU admission was 0.59 (95% CI, 0.46-0.76; P < .001). By comparison, neonates in the intended waterbirth group experienced more negative outcomes than the nonwaterbirth group, although only 5-minute Apgar score was significant (aOR, 2.02; 95% CI, 1.40-2.93; P < 0001). For women, waterbirth (compared to nonwaterbirth) was associated with fewer postpartum transfers (aOR, 0.65; 95% CI, 0.50-0.84; P = .001) and hospitalizations in the first 6 weeks (aOR, 0.72; 95% CI, 0.59-0.87; P < 0.001) but with an increased odds of genital tract trauma (aOR, 1.11; 95% CI, 1.04-1.18; P = .002). Waterbirth was not associated with maternal infection. Women in the intended waterbirth group had increased odds for all maternal outcomes compared to women in the nonwaterbirth group, although only genital tract trauma was significant (aOR, 1.67; 95% CI, 1.49-1.87; P < .001). DISCUSSION Waterbirth confers no additional risk to neonates; however, waterbirth may be associated with increased risk of genital tract trauma for women.
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Kaushik M, Bober B, Eisenfeld L, Hussain N. Case Report of Haemophilus parainfluenzae Sepsis in a Newborn Infant Following Water Birth and a Review of Literature. AJP Rep 2015; 5:e188-92. [PMID: 26495182 PMCID: PMC4603865 DOI: 10.1055/s-0035-1556068] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Accepted: 05/19/2015] [Indexed: 10/27/2022] Open
Abstract
Water birth has grown in popularity over the recent years. Although beneficial for mothers, there are concerns for the infants. There are previous reports of infection following water birth. The information regarding infection with Haemophilus parainfluenzae is limited. We report a case of a neonate with H. parainfluenzae bacteremia following water birth. The child was successfully treated with both antibiotic and supportive care. Previous reports of neonatal H. parainfluenzae infection are reviewed.
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Affiliation(s)
- Manu Kaushik
- Division of Neonatology, Department of Pediatrics, Connecticut Children's Medical Center and University of Connecticut School of Medicine, Farmington, Connecticut
| | - Brittany Bober
- Division of Neonatology, Department of Pediatrics, Connecticut Children's Medical Center and University of Connecticut School of Medicine, Farmington, Connecticut
| | - Leonard Eisenfeld
- Division of Neonatology, Department of Pediatrics, Connecticut Children's Medical Center and University of Connecticut School of Medicine, Farmington, Connecticut
| | - Naveed Hussain
- Division of Neonatology, Department of Pediatrics, Connecticut Children's Medical Center and University of Connecticut School of Medicine, Farmington, Connecticut
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Affiliation(s)
- Kerry Phillips
- Supervisor of Midwives Aneurin Bevan University Health Board Associate Lecturer School of Healthcare Sciences Cardiff University
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Poder TG, Larivière M. [Advantages and disadvantages of water birth. A systematic review of the literature]. ACTA ACUST UNITED AC 2014; 42:706-13. [PMID: 24996877 DOI: 10.1016/j.gyobfe.2014.05.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2013] [Accepted: 04/28/2014] [Indexed: 10/25/2022]
Abstract
CONTEXT Water birth is under debate among professionals. For the proponents of this approach, immersion in water during labour and birth may increase maternal relaxation, reduce analgesia requirements and promote a model of obstetric care more focused on the needs of mothers, particularly the empowerment of women to realize their full potential. In contrast, major critics cite a risk of inhalation of water for the newborn and a risk of infection for the mother and the newborn. OBJECTIVE This review tracks the state of scientific knowledge about water birth in order to determine if it can be generalized in hospitals. METHOD A systematic review of the literature was conducted in PubMed, Embase and Cochrane Database. The period covered is from January 1989 to May 2013. The level of evidence of the studies was assessed with the analysis guide of the Haute Autorité de santé. RESULTS The level of evidence of the studies identified goes from moderate to low, particularly as regard to studies analysing the expulsion phase. CONCLUSION It is possible to recommend immersion in water during the labour phase. No recommendation can be made as regard to the foetal expulsion phase.
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Affiliation(s)
- T G Poder
- UETMIS et CRCHUS, Hôtel-Dieu, CHUS, 580, rue Bowen-Sud, J1G 2E8, Sherbrooke, QC, Canada.
| | - M Larivière
- Direction interdisciplinaire des services cliniques, hôpital Fleurimont, CHUS, 3001, 12(e), avenue Nord, J1H 5N4, Sherbrooke, QC, Canada
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Nutter E, Shaw-Battista J, Marowitz A. Waterbirth Fundamentals for Clinicians. J Midwifery Womens Health 2014; 59:350-4. [DOI: 10.1111/jmwh.12193] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
Immersion in water has been suggested as a beneficial alternative for labor, delivery, or both and over the past decades has gained popularity in many parts of the world. Immersion in water during the first stage of labor may be associated with decreased pain or use of anesthesia and decreased duration of labor. However, there is no evidence that immersion in water during the first stage of labor otherwise improves perinatal outcomes, and it should not prevent or inhibit other elements of care. The safety and efficacy of immersion in water during the second stage of labor have not been established, and immersion in water during the second stage of labor has not been associated with maternal or fetal benefit. Given these facts and case reports of rare but serious adverse effects in the newborn, the practice of immersion in the second stage of labor (underwater delivery) should be considered an experimental procedure that only should be performed within the context of an appropriately designed clinical trial with informed consent. Facilities that plan to offer immersion in the first stage of labor need to establish rigorous protocols for candidate selection, maintenance and cleaning of tubs and immersion pools, infection control procedures, monitoring of mothers and fetuses at appropriate intervals while immersed, and immediately and safely moving women out of the tubs if maternal or fetal concerns develop.
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Harper B. Birth, bath, and beyond: the science and safety of water immersion during labor and birth. J Perinat Educ 2014; 23:124-34. [PMID: 25364216 PMCID: PMC4210671 DOI: 10.1891/1058-1243.23.3.124] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The 2014 objection to birth in water voiced by both the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists (ACOG) in ACOG Bulletin #594 on immersion in water during labor and birth is nothing new. The Committee on Fetus and Newborn published the very same opinion in 2005, based on a case report that was published in 2002 in the journal Pediatrics. What has changed since 2002 is a growing body of evidence that reports on the safety and efficacy of labor and birth in water. This article reviews the retrospective literature on water birth and explains newborn physiology and the protective mechanisms that prevent babies from breathing during a birth in water.
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Young K, Kruske S. How valid are the common concerns raised against water birth? A focused review of the literature. Women Birth 2013. [DOI: 10.1016/j.wombi.2012.10.006] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Mollamahmutoğlu L, Moraloğlu Ö, Özyer Ş, Su FA, Karayalçın R, Hançerlioğlu N, Uzunlar Ö, Dilmen U. The effects of immersion in water on labor, birth and newborn and comparison with epidural analgesia and conventional vaginal delivery. J Turk Ger Gynecol Assoc 2012; 13:45-9. [PMID: 24627674 PMCID: PMC3940223 DOI: 10.5152/jtgga.2012.03] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2011] [Accepted: 11/22/2011] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To document the practice of labour in water, to assess the effects of water immersion during labor and/or birth (labour stages 1, 2 and 3) on maternal, fetal and neonatal wellbeing and to compare the outcomes and safety with conventional vaginal deliveries and deliveries with epidural analgesia. MATERIAL AND METHODS Two-hundred and seven women electing for waterbirth (n=207) were compared with women having conventional vaginal deliveries (n=204) and vaginal deliveries with epidural analgesia (n=191). Demographic data, length of 1(st), 2(nd) and 3(rd) stage of labor, induction and episiotomy requirements, perineal trauma, apgar scores, NICU requirements and VAS scores were noted. RESULTS The 1(st) stage of labor was shorter in waterbirths compared with vaginal delivery with epidural analgesia but the 2(nd) and 3(rd) stage of labor were shortest in patients having waterbirth compared with conventional vaginal delivery and vaginal delivery with epidural analgesia. Patients having waterbirth had less requirement for induction and episiotomy but had more perineal laceration. All women having waterbirths had reduced analgesia requirements and had lower scores on VAS. There was no difference in terms of NICU admission between the groups. Apgar scores were comparable in both groups. There were no neonatal deaths or neonatal infections during the study. CONCLUSION The study demonstrates the advantages of labor in water in terms of reduction in 2(nd) and 3(rd) stage of labor, reduction in pain and obstetric intervention such as induction or amniotomy.
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Affiliation(s)
- Leyla Mollamahmutoğlu
- Water Birth Unit, Zekai Tahir Burak Women’s Health Education and Research Hospital, Ankara, Turkey
| | - Özlem Moraloğlu
- Water Birth Unit, Zekai Tahir Burak Women’s Health Education and Research Hospital, Ankara, Turkey
| | - Şebnem Özyer
- Water Birth Unit, Zekai Tahir Burak Women’s Health Education and Research Hospital, Ankara, Turkey
| | - Filiz Akın Su
- Water Birth Unit, Zekai Tahir Burak Women’s Health Education and Research Hospital, Ankara, Turkey
| | - Rana Karayalçın
- Water Birth Unit, Zekai Tahir Burak Women’s Health Education and Research Hospital, Ankara, Turkey
| | - Necati Hançerlioğlu
- Water Birth Unit, Zekai Tahir Burak Women’s Health Education and Research Hospital, Ankara, Turkey
| | - Özlem Uzunlar
- Water Birth Unit, Zekai Tahir Burak Women’s Health Education and Research Hospital, Ankara, Turkey
| | - Uğur Dilmen
- Neonatology Unit, Zekai Tahir Burak Women’s Health Education and Research Hospital, Ankara, Turkey
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Thoeni A, Zech N, Moroder L, Ploner F. Review of 1600 water births. Does water birth increase the risk of neonatal infection? J Matern Fetal Neonatal Med 2009; 17:357-61. [PMID: 16147851 DOI: 10.1080/14767050500140388] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVES We reviewed 1600 water births at a single institution over an 8-year period. METHODS We compared 737 primiparae deliveries in water with 407 primiparae deliveries in bed, and 142 primiparae on the delivery stool. We also evaluated the duration of labor, perineal trauma, arterial cord blood pH, postpartum maternal hemoglobin levels, and rates of neonatal infection. In 250 water deliveries we performed bacterial cultures of water samples obtained from the bath after filling and after delivery. RESULTS The duration of the first stage of labor was significantly shorter with a water birth than with a land delivery (380 vs. 468 minutes, P<0.01). The episiotomy rate in all water births was lower with a water birth than with a delivery in bed or a delivery on the birthing stool (0.38%, 23%, and 8.4%, respectively). The rate of perineal tears was similar (23%, respectively). There were no differences in the duration of the second stage (34 vs. 37 minutes), arterial cord blood pH, or postpartum maternal hemoglobin levels. No woman using the water birth method required analgesics. The rate of neonatal infection was also not increased with a water birth (1.22% vs. 2.64%, respectively). CONCLUSION Water birth appears to be associated with a significantly shorter first stage of labor, lower episiotomy rate and reduced analgesic requirements when compared with other delivery positions. If women are selected appropriately and hygiene rules are respected, water birth appears to be safe for both the mother and neonate.
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Affiliation(s)
- A Thoeni
- Department of Gynaecology and Obstetrics, Vipiteno/Sterzing, Italy.
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Abstract
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. AUTHORS' CONCLUSIONS Evidence suggests that water immersion during the first stage of labour reduces the use of epidural/spinal analgesia. There is limited information for other outcomes related to water use during the first and second stages of labour, due to intervention and outcome variability. There is no evidence of increased adverse effects to the fetus/neonate or woman from labouring in water or waterbirth. The fact that use of water immersion in labour and birth is now a widely available care option for women threatens the feasibility of a large, multicentre randomised controlled trial.
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Affiliation(s)
- Elizabeth R Cluett
- School of Health Sciences , University of Southampton, Nightingale Building (67), Highfield, Southampton, Hants, UK, SO17 1BJ.
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Maude RM, Foureur MJ. It's beyond water: Stories of women's experience of using water for labour and birth. Women Birth 2007; 20:17-24. [PMID: 17174165 DOI: 10.1016/j.wombi.2006.10.005] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2006] [Revised: 10/27/2006] [Accepted: 10/27/2006] [Indexed: 10/23/2022]
Abstract
PURPOSE This study aimed to give 'voice' to women's experiences of using water for labour and birth. PARTICIPANTS Five women from a large urban region in New Zealand, who used water for labour and birth, at home and in hospital. METHODS The study employed an interpretive design using audio-taped conversations as the method of data collection and a thematic analysis of the women's stories. FINDINGS Data analysis produced two core categories; 'Getting to the water' which revealed the impact of preparing for and anticipating the water; and 'Getting into the water' which provided a sanctuary and a release from pain. CONCLUSION The all-encompassing warmth associated with being enveloped in warm water cradled, supported, relaxed, comforted, soothed, sheltered and protected the women; it created a barrier and offered a sense of privacy. Water can be used in any form, even the act of thinking about, preparing for and anticipating the water opened possibilities for these women. The women used water to reduce their fear of pain and of childbirth itself; to cope with pain, not necessarily to remove or diminish pain; and to maintain control over the process of birth. The women indicated that it was not necessary to actually give birth in the water to achieve these benefits. Listening to the stories of women provides us with insights into what is important to them. Women's knowledge contributes an important part of the evidence on which we base our practice.
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Affiliation(s)
- Robyn M Maude
- Graduate School of Nursing, Midwifery and Health, Victoria University of Wellington, Wellington, New Zealand.
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Thoni A, Zech N, Moroder L, Ploner F. Die Kontamination des Wassers und die Infektionsrate bei der Wassergeburt. ACTA ACUST UNITED AC 2007; 47:33-8. [PMID: 17272934 DOI: 10.1159/000098123] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2005] [Accepted: 05/05/2006] [Indexed: 11/19/2022]
Abstract
OBJECTIVE This study aimed at examining the water of the birthing tub for pathogenic germs and at comparing the infection rates of the children born conventionally. METHOD In a prospective study, the germs found in the water of 300 water births were determined . The tub water was sampled twice: sample A was taken after filling the tub with tap water, sample B after the water delivery. In addition, the paediatrician documented any signs of infection of the neonates during their hospital stay. RESULTS The A samples contained Legionella in 29%, Pseudomonas aeruginosa in 22%, enterococci in 18%, colibacilli in 32% and Escherichia coli in 8%. After fitting a filter system, no Legionella was detected any more. P. aeruginosa was found in only 3% of the samples. In the B samples, we found an increased contamination by colibacilli in 81%. A marked burden with E. coli was detected in 58% of the samples. Due to a clinically an biochemically suspected beginning infection, 1.15% of the water-born children (14 out of 1,215) were given antibiotics. In contrast, 2.30% of the conventionally born neonates (19 out of 817) were treated with antibiotics. CONCLUSION It is evident that during the bearing-down phase faeces are discharged into the birthing tube and that the water is contaminated mainly by E. coli and colibacilli, but also slightly by Staphylococcus aureus. The contamination of the tap water by Legionella and Pseudomonas could clearly be reduced by installation of a filter system into the supply hose of the birthing tub. Neonatal infections were not more frequent after water births than after conventional deliveries.
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Affiliation(s)
- A Thoni
- Geburtshilflich-gynakologische Abteilung, Landeskrankenhaus Sterzing, Sterzing, Italien.
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Freeman LM, Griew K. Enhancing the midwife-woman relationship through shared decision making and clinical guidelines. Women Birth 2006; 20:11-5. [PMID: 17127115 DOI: 10.1016/j.wombi.2006.10.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2006] [Indexed: 11/30/2022]
Abstract
The active and passive voice allocated to women within maternity service guidelines helps construct the nature of decision making. The aim of this paper is to demonstrate that by allocating women an active voice within practice guidelines serves the interest of all parties within the health care relationship. Clinical guidelines were reviewed, and electronic databases and text were searched. The findings of this paper support that applying the principles of a shared decision making framework, within clinical practice guidelines, can assist the development of a partnership relationship between midwives and women.
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Affiliation(s)
- Lesa M Freeman
- Faculty of Nursing and Midwifery, The University of Sydney, Sydney, NSW, Australia.
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Affiliation(s)
- Zainab Kassim
- Department of Child Health, Guy's, King's and St Thomas' School of Medicine, King's College Hospital, London SE5 9RS
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Geissbuehler V, Stein S, Eberhard J. Waterbirths compared with landbirths: an observational study of nine years. J Perinat Med 2004; 32:308-14. [PMID: 15346814 DOI: 10.1515/jpm.2004.057] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
AIMS This study compares neonatal and maternal morbidity and mortality between waterbirths and landbirths (spontaneous singleton births in cephalic presentation, vacuum extractions are excluded). METHODS In this observational study covering nine years, standardized questionnaires were used to document 9,518 spontaneous singleton cephalic presentation births, of which 3,617 were waterbirths and 5,901 landbirths. RESULTS Landbirths show higher rates of episiotomies as well as third and fourth degree perineal lacerations. Waterbirths show a higher rate of births "without injuries", first and second-degree perineal lacerations, vaginal and labial tears. After a waterbirth, there is an average loss of 5.26 g/l blood; this is significantly less than landbirths where there is an 8.08 g/l blood loss on average. In 69.7% waterbirths required no analgesic, compared to 58.0% for landbirths. Water and landbirths do not differ with respect to maternal and neonatal infections. After landbirths, there was a higher rate of newborn complications with subsequent transfer to an external NICU. During the study, there were neither maternal nor neonatal deaths related to spontaneous labor. CONCLUSIONS Waterbirths are associated with low risks for both mother and child when obstetrical guidelines are followed.
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Affiliation(s)
- Verena Geissbuehler
- Department of Obstetrics and Gynecology, Cantonal Hospital, Frauenfeld, Switzerland.
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Abstract
BACKGROUND Enthusiasts for immersion in water during labour, and birth have advocated its use to increase maternal relaxation, reduce analgesia requirements and promote a midwifery model of supportive care. Sceptics are concerned that there may be greater harm to women and/or babies, for example, a perceived risk associated with neonatal inhalation of water and maternal/neonatal infection. OBJECTIVES To assess the evidence from randomised controlled trials about the effects of immersion in water during pregnancy, labour, or birth on maternal, fetal, neonatal and caregiver outcomes. SEARCH STRATEGY We searched the Cochrane Pregnancy and Childbirth Group trials register (September 2003). SELECTION CRITERIA All randomised controlled trials comparing any kind of bath tub/pool with no immersion during pregnancy, labour or birth. DATA COLLECTION AND ANALYSIS We assessed trial eligibility and quality and extracted data independently. One reviewer entered the data and another checked them for accuracy. MAIN RESULTS : Eight trials are included (2939 women). No trials were identified that evaluated immersion versus no immersion during pregnancy, considered different types of baths/pools, or considered the management of third stage of labour. There was a statistically significant reduction in the use of epidural/spinal/paracervical analgesia/anaesthesia amongst women allocated to water immersion water during the first stage of labour compared to those not allocated to water immersion (odds ratio (OR) 0.84, 95% confidence interval (CI) 0.71 to 0.99, four trials). There was no significant difference in vaginal operative deliveries (OR 0.83, 95% CI 0.66 to 1.05, six trials), or caesarean sections (OR 1.33, 95% CI 0.92 to 1.91). Women who used water immersion during the first stage of labour reported statistically significantly less pain than those not labouring in water (40/59 versus 55/61) (OR 0.23, 95% CI 0.08 to 0.63, one trial). There were no significant differences in incidence of an Apgar score less than 7 at five minutes (OR 1.59, 95% CI 0.63 to 4.01), neonatal unit admissions (OR 1.05, 95% CI 0.68 to 1.61), or neonatal infection rates (OR 2.01, 95% CI 0.50 to 8.07). REVIEWERS' CONCLUSIONS There is evidence that water immersion during the first stage of labour reduces the use of analgesia and reported maternal pain, without adverse outcomes on labour duration, operative delivery or neonatal outcomes. The effects of immersion in water during pregnancy or in the third stage are unclear. One trial explores birth in water, but is too small to determine the outcomes for women or neonates.
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Affiliation(s)
- E R Cluett
- School of Nursing and Midwifery, University of Southampton, Nightingale Building (67), Highfield, Southampton, Hants, UK, SO17 1BJ
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Gilbert RE, Tookey PA. Perinatal mortality and morbidity among babies delivered in water: surveillance study and postal survey. BMJ (CLINICAL RESEARCH ED.) 1999; 319:483-7. [PMID: 10454400 PMCID: PMC28200 DOI: 10.1136/bmj.319.7208.483] [Citation(s) in RCA: 73] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
AIM To compare perinatal morbidity and mortality for babies delivered in water with rates for babies delivered conventionally (not in water). DESIGN Surveillance study (of all consultant paediatricians) and postal survey (of all NHS maternity units). SETTING British Isles (surveillance study); England and Wales (postal survey). SUBJECTS Babies born in the British Isles between April 1994 and March 1996 who died perinatally or were admitted for special care within 48 hours of birth after delivery in water or after labour in water followed by conventional delivery (surveillance study); babies delivered in water in England and Wales in the same period (postal survey). MAIN OUTCOME MEASURESE Number of deliveries in water in the British Isles that resulted in perinatal death or in admission to special care within 48 hours of birth; and proportions (of such deliveries) of all water births in England and Wales. RESULTS 4032 deliveries (0.6% of all deliveries) in England and Wales occurred in water. Perinatal mortality was 1.2/1000 (95% confidence interval 0.4 to 2.9) live births; 8.4/1000 (5.8 to 11.8) live births were admitted for special care. No deaths were directly attributable to delivery in water, but 2 admissions were for water aspiration. UK reports of mortality and special care admission rates for babies of women considered to be at low risk of complications during delivery who delivered conventionally ranged from 0.8/1000 (0. 2 to 4.2) to 4.6/1000 (0.1 to 25) live births and from 9.2 (1.1 to 33) to 64/1000 (58 to 70) live births respectively. Compared with regional data for low risk, spontaneous, normal vaginal deliveries at term, the relative risk for perinatal mortality associated with delivery in water was 0.9 (99% confidence interval 0.2 to 3.6). CONCLUSIONS Perinatal mortality is not substantially higher among babies delivered in water than among those born to low risk women who delivered conventionally. The data are compatible with a small increase or decrease in perinatal mortality for babies delivered in water.
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Affiliation(s)
- R E Gilbert
- Department of Epidemiology and Public Health, Institute of Child Health, London WC1N 1EH.
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Affiliation(s)
- Laura Ginesi
- lecturers in Human Biology at City College, Norwich. They are also National Childbirth Trust teachers
| | - Rose Niescierowicz
- lecturers in Human Biology at City College, Norwich. They are also National Childbirth Trust teachers
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Affiliation(s)
- Lyn Brown
- Senior Midwife, Labour Ward and Audit Midwife, Good Hope NHS Trust, Birmingham
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Affiliation(s)
- Dianne Garland
- Senior Midwife Practice and Research at Maidstone Hospital, Kent
| | - Keith Jones
- Honorary Research Fellow in Health Services Studies, University of Kent
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Hofmeyr GJ, Nikodem VC, De Jagert M. Birth under water--to breathe or not to breathe. BRITISH JOURNAL OF OBSTETRICS AND GYNAECOLOGY 1997; 104:121. [PMID: 8988715 DOI: 10.1111/j.1471-0528.1997.tb10668.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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