Immersion in water in labour and birth

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.

Enhancing the midwife-woman relationship through shared decision making and clinical guidelines

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.

A pilot study for a randomised controlled trial of waterbirth versus land birth

OBJECTIVES

To assess the feasibility of undertaking an adequately powered multicentre study comparing waterbirth with land birth. To assess whether women are willing to participate in such a trial and whether participation has a negative effect on their birthing experience.

DESIGN

A randomised controlled trial (RCT) with 'preference arm'.

SETTING

District general hospital with 3600 deliveries annually.

POPULATION

Women with no pregnancy complications and no anticipated problems for labour/delivery.

METHODS

Women were recruited and randomised between 36 and 40 weeks of gestation. Comparison of randomised and 'preference arm' to assess any impact of randomisation on women's birthing experience.

MAIN OUTCOME MEASURES

Data were collected at delivery concerning the labour, the pool water and baby's condition at birth and six weeks of age. The main outcome measures are means and standard deviation of cord O(2), CO(2), haemoglobin, haematocrit and base excess; medians and ranges of time to first breathe and cord pH; bacterial growth from pool water samples and neonatal swabs; and maternal satisfaction.

RESULTS

Eighty women participated-60 women were randomised. Twenty women participated in a non-randomised 'preference arm'. The babies randomised to a waterbirth demonstrated a significantly lower umbilical artery pCO(2) (P= 0.003); however, it is recognised that this study is underpowered. Women were willing to participate and randomisation did not appear to alter satisfaction.

CONCLUSION

This small study has shown that a RCT is feasible and demonstrated outcome measures, which can be successfully collected in an average delivery suite.

Waterbirth: water temperature and bathing time--mother knows best!

OBJECTIVES

The Frauenfeld Clinic for Obstetrics and Gynecology introduced waterbirths in 1991. This work examines whether guidelines for water temperature and bathing are actually necessary.

METHODS

This 8-year prospective clinical study follows 10,775 births in a regional women's hospital (non-selected population). Neonatal and maternal body temperature and morbidity parameters were compared between land and waterbirths. A smaller study (n = 47) selectively focused on body temperature differences as influenced by bathing time and water temperature in waterbirths as compared to land births.

RESULTS

Neonatal and maternal birth and perinatal parameters, and body temperatures do not differ between water and land births, except at birth, when waterbearing temperatures were 36.9 degrees C vs. 36.3 degrees C on land. Neonatal rectal temperatures did not differ significantly between the two groups. Water temperature increased from the beginning of the bath (35.2 degrees C) to 35.7 degrees C, and fell at the end of the bath to 32.9 degrees C. Water temperature range: 23 degrees C to 38.9 degrees C. Bathing duration: 28 min. to 364 min.

CONCLUSIONS

Waterbirths pose no thermal risk. The parturient, with her "inborn code of body temperature regulation," regulates water temperature and bathing duration to ensure body temperatures of mother and child remain within the physiological range. Cumbersome guidelines for water temperature and bathing duration are therefore superfluous.

Caring control: methodological issues in a discourse analysis of waterbirth texts

This paper describes a study where the discourses surrounding waterbirth were identified by an analysis of texts in professional journals and broadsheet newspapers. While one particular discourse, caring control, will be discussed, the focus of the paper is on the method of discourse analysis. What discourse analysis can offer nurses and midwives is a position from which to analyse systematically and to arrive at some understanding of how oppression and inequality of power relations, which are inherent in many forms of health care provision, are created and sustained.