Article

Waterbirth Fundamentals for Clinicians

Authors:
  • CommuniCare Health Centers
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Abstract

Introduction: Despite a growing body of evidence for waterbirth safety, a myriad of political and cultural issues result in limited use in US hospitals compared to other developed nations. The purpose of this article is to critically analyze the evidence on maternal and neonatal outcomes of waterbirth to help inform evidence-based clinical practice in the United States. Methods: A literature search was performed using electronic databases CINAHL, Ovid MEDLINE, PubMed, EMBASE, and PsycINFO. Thirty-eight studies, including 2 randomized controlled trials and 36 observational studies, were reviewed. Studies were conducted in 11 countries, mostly outside the United States. More than 31,000 waterbirths were described. Results: Aggregate results suggest that waterbirth is associated with high levels of maternal satisfaction with pain relief and the experience of childbirth, and may increase the likelihood of an intact perineum. Waterbirth is associated with decreased incidence of episiotomy and severe perineal lacerations, and may contribute to reduced postpartum hemorrhage. Data indicate no difference in maternal or neonatal infection rates or nursery admissions after waterbirth. Neonatal mortality rates are low and similar after waterbirth and uncomplicated conventional birth. The calculated cord avulsion rate is 2.4 per 1000 waterbirths; it is unknown how this compares to conventional birth due to a lack of data that permits direct comparison. Discussion: The majority of waterbirth research to date is observational and descriptive; thus, reported outcomes do not demonstrate causal associations. However, existing evidence is reassuring. Case-controlled studies have included thousands of women who gave birth underwater without an apparent increase in maternal or neonatal morbidity or mortality. Potential risks associated with waterbirth for women and neonates appear minimal, and outcomes are comparable to those expected in any healthy childbearing population.

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... The Commission for the Accreditation of Birth Centers' Indicators of Compliance with Standards for Birth Centers includes specific criteria for birth centers offering water birth, including the implementation of exclusion criteria, water temperature guidelines, maternal and fetal assessment while in the water, tub cleaning protocols, staff training, and emergency drills addressing management of complications when the client is in the water. 49 Ongoing risk screening and clinical judgment were demonstrated in the comparative outcomes within this sample. This is evident in the outcomes such as utilization of pharmacologic pain management, incidence of shoulder dystocia, and episiotomy. ...
... 50 Researchers speculate that cord avulsion results from bringing the newborn rapidly to the surface of the water following birth. 12,49,50 Among the measures believed to reduce the risk of cord avulsion include recognition of the potential for cord avulsion, lowering the water level prior to birth, and bringing the newborn to the water surface gently. Although experienced water birth providers are often able to avoid cord avulsion, more research is needed to evaluate the effectiveness of these measures. ...
Article
Consumer demand for water birth has grown within an environment of professional controversy. Access to nonpharmacologic pain relief through water immersion is limited within hospital settings across the United States due to concerns over safety. The study is a secondary analysis of prospective observational Perinatal Data Registry (PDR) used by American Association of Birth Center members (AABC PDR). All births occurring between 2012 and 2017 in the community setting (home and birth center) were included in the analysis. Descriptive, correlational, and relative risk statistics were used to compare maternal and neonatal outcomes. Of 26 684 women, those giving birth in water had more favorable outcomes including fewer prolonged first- or second-stage labors, fetal heart rate abnormalities, shoulder dystocias, genital lacerations, episiotomies, hemorrhage, or postpartum transfers. Cord avulsion occurred rarely, but it was more common among water births. Newborns born in water were less likely to require transfer to a higher level of care, be admitted to a neonatal intensive care unit, or experience respiratory complication. Among childbearing women of low medical risk, personal preference should drive utilization of nonpharmacologic care practices including water birth. Both land and water births have similar good outcomes within the community setting.
... 5-7 However, intrapartum use remains limited compared with pharmacologic labor pain relief methods, and hydrotherapy utilization rates vary widely by country. 4,8,9 Warm water immersion hydrotherapy warrants further investigation ...
... 68 Best practices in hydrotherapy have been published with supporting data and can be used to create site-specific health information materials 69 and clinical policies and procedures as needed. 9,30,70,71 Additional considerations for healthcare providers include safe tub filling and cleaning, 9 financial costs, 49 and risk reduction with robust documentation practices as well as preparation for inadvertent underwater birth. ...
Article
Health sciences research was systematically reviewed to assess randomized controlled trials of standard care versus immersion hydrotherapy in labor before conventional childbirth. Seven studies of 2615 women were included. Six trials examined hydrotherapy in midwifery care and found an effect of pain relief; of these, 2 examined analgesia and found reduced use among women who bathed in labor. One study each found that hydrotherapy reduced maternal anxiety and fetal malpresentation, increased maternal satisfaction with movement and privacy, and resulted in cervical dilation progress equivalent to standard labor augmentation practices. Studies examined more than 30 fetal and neonatal outcomes, and no benefit or harm of hydrotherapy was identified. Two trials had anomalous findings of increased newborn resuscitation or nursery admission after hydrotherapy, which were not supported by additional results in the same or other studies. Review findings demonstrate that intrapartum immersion hydrotherapy is a helpful and benign practice. Hydrotherapy facilitates physiologic childbirth and may increase satisfaction with care. Maternity care providers are recommended to include hydrotherapy among routine labor pain management options and consider immersion to promote progress of normal or protracted labor, particularly among women with preferences to avoid obstetric medications and procedures.
... 5-7 However, intrapartum use remains limited compared with pharmacologic labor pain relief methods, and hydrotherapy utilization rates vary widely by country. 4,8,9 Warm water immersion hydrotherapy warrants further investigation ...
... 68 Best practices in hydrotherapy have been published with supporting data and can be used to create site-specific health information materials 69 and clinical policies and procedures as needed. 9,30,70,71 Additional considerations for healthcare providers include safe tub filling and cleaning, 9 financial costs, 49 and risk reduction with robust documentation practices as well as preparation for inadvertent underwater birth. ...
Article
Health sciences research was systematically reviewed to assess randomized controlled trials of standard care versus immersion hydrotherapy in labor before conventional childbirth. Seven studies of 2615 women were included. Six trials examined hydrotherapy in midwifery care and found an effect of pain relief; of these, 2 examined analgesia and found reduced use among women who bathed in labor. One study each found that hydrotherapy reduced maternal anxiety and fetal malpresentation, increased maternal satisfaction with movement and privacy, and resulted in cervical dilation progress equivalent to standard labor augmentation practices. Studies examined more than 30 fetal and neonatal outcomes, and no benefit or harm of hydrotherapy was identified. Two trials had anomalous findings of increased newborn resuscitation or nursery admission after hydrotherapy, which were not supported by additional results in the same or other studies. Review findings demonstrate that intrapartum immersion hydrotherapy is a helpful and benign practice. Hydrotherapy facilitates physiologic childbirth and may increase satisfaction with care. Maternity care providers are recommended to include hydrotherapy among routine labor pain management options and consider immersion to promote progress of normal or protracted labor, particularly among women with preferences to avoid obstetric medications and procedures.
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When women are pregnant, some plan to have waterbirths and other plan to have traditional bedbirths. Therefore some neonates will be born under water and other neonates out of the water on a bed. It is unclear what the outcomes for the neonates are after these two types o f deliveries. The research goals of this study were to explore and describe the outcomes for neonates after waterbirths (group A) and traditional bedbirths (group B) and to generate hypotheses based on the outcomes for neonates after waterbirths and traditional bedbirths that need to be tested in subsequent research studies. The design was an explorative descriptive survey. The mothers were purposefully selected to participate in the research study. They had to be healthy, low-risk pregnant women with a single pregnancy and a cephalic presentation. They had to be 37 to 42 weeks pregnant. Group A delivered their neonates at two private hospitals in Gauteng and group B delivered their neonates at a government hospital in Gauteng. Data was collected during labour, just after the delivery, two hours after the delivery and 14 days after the delivery. A data collection instrument was used. The following neonatal outcomes were measured: Apgar score at one and five minutes, axillary temperature, pH-, haemoglobin- and sodium levels of the umbilical cord blood, the neurological condition of the neonate as reflected by the primitive reflexes and neonatal morbidity until 14 days after birth. Descriptive analysis was used to analyse the data. It appeared if group A had higher Apgar scores, neonatal temperatures and umbilical cord blood haemoglobin levels and lower sodium umbilical cord blood levels than group B. The umbilical cord blood pH levels, neonatal morbidity and primitive reflexes o f both groups appeared equal. Group B needed more resuscitation of the neonate directly after birth than group A. Hypotheses were generated that need to be tested in subsequent research.
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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. 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. 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. 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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Birthing pools are integrated into maternity care in the United Kingdom and are a popular care option for women in midwifery-led units and at home. The objective of this study was to describe and compare maternal characteristics, intrapartum events, interventions, and maternal and neonatal outcomes by planned place of birth for women who used a birthing pool. A total of 8,924 women at low risk of childbirth complications were recruited from care settings in England, Scotland, and Northern Ireland. Descriptive analysis was performed. Overall, 7,915 (88.9%) women had a spontaneous birth (5,192, 58.3% water births), of whom 4,953 (55.5%) were nulliparas. Fewer nulliparas whose planned place of birth was the community (freestanding midwifery unit or home) had labor augmentation by artificial membrane rupture (149, 11.3% [95% CI: 9.6-13.1]), compared with an alongside midwifery unit (271, 22.7% [95% CI: 20.3-25.2]), or obstetric unit (639, 26.3% [95% CI: 24.5-28.1]). Results were similar for epidural analgesia and episiotomy. More community nulliparas had spontaneous birth (1,172, 88.9% [95% CI: 87.1-90.6]), compared with birth in an alongside midwifery unit (942, 79% [95% CI: 76.6-81.3]) and obstetric unit (1,923, 79.2% [95% CI: 77.5-80.8]); and fewer required hospital transfer (265, 20% [95% CI: 17-22.2]) compared with those in an alongside midwifery unit (370, 31% [95% CI: 28.3-33.7]). Results for multiparas and newborns were similar across care settings. Twenty babies had an umbilical cord snap, 18 (90%) of which occurred during water birth. Birthing pool use was associated with a high frequency of spontaneous birth, particularly among nulliparas. Findings revealed differences in midwifery practice between obstetric units, alongside midwifery units, and the community, which may affect outcomes, particularly for nulliparas. No evidence was found for a difference across care settings in interventions or outcomes in multiparas or in outcomes for newborns. During water birth, it is important to prevent undue traction on the cord as the baby is guided to the surface. (BIRTH 39:3 September 2012).
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Background: Water birth involves the complete birth of the baby under warm water. There is a lack of consensus regarding the safety of water birth. Aim: This study aimed to describe the maternal and neonatal outcomes associated with water birth among labouring women deemed at low risk for obstetric complications and compare these outcomes against women of similar risk who had a standard land birth. Method: A retrospective audit and comparison of women giving birth in water with a matched cohort who birthed on land at Bankstown hospital over a 10 year period (2000-2009). Results: In total 438 childbearing women were selected for this study (N=219 in each arm). Primigravida women represented 42% of the study population. There was no significant difference in mean duration of both first and second stages of labour or postpartum blood loss between the two birth groups. There were no episiotomies performed in the water birth arm which was significantly different to the comparison group (N=33, p<0.001). There were more babies in the water birth group with an Apgar score of 7 or less at 1min (compared to land births). However, at 5min there was no difference in Apgar scores between the groups. Three of eight special care nursery admissions in the water birth group were related to feeding difficulties. Conclusion: This is the largest study on water birth in an Australian setting. Despite the limitations of a retrospective audit the findings make a contribution to the growing body of knowledge on water birth.
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Background: the option of giving birth in water is available to most women in birth centres in Australia but there continues to be resistance in mainstream delivery wards due to safety concerns. Women in birth centres are more likely to give birth in upright positions and be attended by experienced midwives and obstetricians who are comfortable facilitating normal birth. The aim of this study was to determine rates of perineal trauma, postpartum haemorrhage and five-minute Apgar scores amongst low risk women in a birth centre who gave birth in water compared to six birth positions on land. Methods: this was a descriptive cross sectional study of births occurring in a large alongside Sydney birth centre from January 1996 to April 2008. Handwritten records were kept by midwives on each birth in the birth centre over twelve and a half years (n=6,144). Descriptive statistics and logistic regression were applied controlling for risk factors for perineal trauma, postpartum haemorrhage and the five-minute Apgar score. Findings: waterbirth (13%) and six main birth positions on land were identified: kneeling/all fours (48%), semi-recumbent (12%), lateral (5%), standing (8%), birth stool (10%) and squatting (3%). Compared to waterbirth, birth on a birth stool led to a higher rate of major perineal trauma (second, third, fourth degree tear and episiotomy) (OR 1.40 [1.12-1.75]) and postpartum haemorrhage (OR 2.04 [1.44-2.90]). Compared to waterbirth, babies born in a semi-recumbent position had a significantly greater incidence of five-minute Apgar scores <7 (OR 4.61 [1.29-16.52]). Conclusions: waterbirth does not lead to more infants born with Apgar score <7 at 5 mins when compared to other birth positions. Waterbirth provides advantages over the birth stool for maternal outcomes of major perineal trauma and postpartum haemorrhage.
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Having considered the physiologic challenges during pregnancy, scientists have searched for different delivery methods with minimal medical intervention. The use of water immersion by women for relaxing during labor is being used worldwide. We aimed to evaluate the controversies surrounding water birth and to find out the interest of Iranian women in this delivery method. In a randomized clinical trial, 106 pregnant women were assigned to control and experimental groups. The experimental group underwent the labor and delivery in standardized warm water pools. The control group gave birth by conventional delivery method at the hospital. A questionnaire was completed during the labor for women in both control and experimental groups including the method of delivery; labor length; use of different drugs such as analgesics, opiates, antispasmodic, and oxytocin; use of episiotomy, and newborn's Apgar score and weight. Totally, 53 cases and 53 controls with the mean age of 26.4+/-5.9 and 27.1+/-5.9 years, respectively, completed the study. Women in the control group required oxytocin, antispasmodics, opiates, and analgesics more frequently than those in the experimental group (P<0.001). Meanwhile, the active phase and the third stage of labor were shorter experimental group by 72 and 1.3 minutes, respectively (P<0.004, and P<0.04). All the participants in the experimental group gave birth naturally, whereas only 79.2< of the controls had normal vaginal delivery. Our results revealed the advantage of water birth delivery. Those who gave water birth experienced less pain and completed the delivery sooner. Meanwhile, normal vaginal delivery was accomplished more frequently with this group. These all lead to a decreased necessity for medical interventions as well as an increased socioeconomic advantage for the society.
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To compare perinatal morbidity and mortality for babies delivered in water with rates for babies delivered conventionally (not in water). Surveillance study (of all consultant paediatricians) and postal survey (of all NHS maternity units). British Isles (surveillance study); England and Wales (postal survey). 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. 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). 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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This study compares neonatal and maternal morbidity and mortality between waterbirths and landbirths (spontaneous singleton births in cephalic presentation, vacuum extractions are excluded). 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. 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. Waterbirths are associated with low risks for both mother and child when obstetrical guidelines are followed.
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Labor is one of the most painful experiences in a woman's life. Does water birth influence the pain experienced? Data from an ongoing, longitudinal, prospective observational study that spans 9 years and includes questionnaires from 12,040 births were used to evaluate pain perception (visual analogue scale (VAS)) and analgesic use. Three birthing methods were compared: water birth, bed birth and Maia stool birth. Based on the VAS, the data show that the different birthing methods do not influence the intensity of pain throughout the different stages of labor. The only significant difference noted was that bed births are more painful in the early first stage, and less painful at the end of the second stage. This later difference may be due to increased use of epidural anesthesia in women choosing a bed birth. Women who choose bed births are significantly less likely than others to have an analgesic-free birth. For primiparas, there is also a small but significant difference showing that water births are less likely to require analgesics compared to Maia stool births. No such difference is seen in women who have given birth previously. We conclude that women who choose bed births perceive more pain in the early first stage of labor, leading them to be more likely to choose an epidural anesthesia in the late first stage, or to use other types of analgesics. Women who choose water births or Maia stool births are more likely to get through labor without using any analgesics.
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Water birth became popular in the last years, despite the fact that many questions like the risk of infection for the newborn remain unanswered. Group B streptococcal (GBS) infections in the newborn remain a challenge in obstetrics and neonatology. We conducted a prospective trial to study the impact of water birth on the colonization rate of the bath water and, more importantly, the GBS-colonization rate of the newborn. After water birth the bath water was significantly more often colonized with GBS than after immersion followed by a delivery in bed. The newborns, however, showed no difference in GBS colonization and there was even a trend towards less GBS colonization of the newborn after a water delivery. Regarding GBS colonization of the newborn during water birth there might be a wash out effect, which protects the children during the delivery.
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To prospectively assess the effect of water birth on maternal and fetal outcomes in a selected low-risk collective of a tertiary obstetrical unit. In this prospective observational study, 513 patients of a low-risk collective, who requested a water birth, were studied during the years 1998-2002. Primary outcome measurements included the maternal and fetal parameters. Secondary outcome measurements comprised data on the incidence of water births in an interested, low-risk population in an academic hospital. All groups were similar in terms of demographic and obstetric data. Significant differences were observed in maternal outcome parameters, which included the use of analgesia/anesthesia during labor, the duration of first and second stages of labor, perineal tears and episiotomy rate. No differences were seen in all observed fetal outcome parameters including APGAR scores, arterial and venous pH, admission rate to neonatal intensive care unit and infection rate. Water birth is a valuable and promising alternative to traditional delivery methods. The maternal and fetal outcomes were similar to traditional land births. However, currently there still exist some deficits in the scientific evaluation of its safety. Therefore, the selection of a low-risk collective is essential to minimize the risks with the addition of strictly maintained guidelines and continuous intrapartum observation and fetal monitoring. Based on our results and the literature, water births are justifiable when certain criteria are met and risk factors are excluded.
Article
Objective: To assess the effects of delivery in water, as a normal way of delivery without intervention, in reducing the pain and duration of delivery. Methodology: This is a clinical trial studying a community of Gravida one and two pregnant women at the gestational age of 38-42 weeks, referred to Asalian hospital. The sample volume was 100 cases, equally divided in two groups of routine delivery and delivery in water. The pain and duration of delivery were analyzed using K-square, Kruskal-wiallis, and mann whitney, with pv<0.05 considered significant. Results: The findings show that the average duration of active delivery was 3.1 hrs ± 0.8 in the delivery in water group, significantly lower than that of the other group, that is, 4.7 hrs ± 0.8 (p<0.05). Also the average of the second phase of delivery was 0.53 hrs ± 0.22 in the delivery in water group, significantly lower than that of the routine group, that is, 0.88 hrs ± 0.43 (p<0.05). The amount of pain was measured in both groups using the visual analog score, yielding 3.53 ± 0.79 in delivery in water, and 6.9 ± 1.7 in the other group, which indicates a significant decrease in pain in delivery in water (p<0.05). Conclusion: This study indicates that delivery in water may be a suitable, nonmedical, and non invasive alternative, because it reduces the pain and duration of delivery.
Article
In 1993 Good Hope NHS Trust in the Midlands responded to client demand for a birthing pool, and a temporary one was installed. Due to its popularity, a permanent pool was installed in 1994 with the number of women booking to use it rising from 5% to 12%. Over a three year period, 1082 women booked to use the pool, and out of the 541 who entered the pool, 343 delivered in it, including 10 women who had previously had a caesarean section. There was one neonatal death that was not attributed to the use of the pool. Evidence obtained over a three year period, 1994–1996, is presented alongside the observations and experiences of the midwives involved. Data from the audit suggests that labour and birth in water is no more dangerous for low risk women than ‘land birth.’ Women like it, as they feel in control of their labour, finding it a rewarding experience.
Article
The objective of this study was to determine basic data on maternal and neonatal well-being and infection risk in a group of low-risk women using a water pool for delivery. A prospective non-randomized method was followed. Delivery details and complications were recorded, and post-delivery patient satisfaction questionnaires were completed. Forty-nine women delivered in the pool. There was no clinically significant neonatal infection, however, there were some positive maternal and neonatal swabs. Although two babies required basic resuscitation and some babies had transient abnormalities of postnatal observations, there was no evidence of serious neonatal morbidity. The data analysed in this study did not suggest any increased risk of bacterial infection to the mother or baby after delivery underwater. The neonatal observations suggest that neonatal morbidity is rare after waterbirth in a carefully selected group of mothers and with close attention to fetal and neonatal well-being. We recommend that protocols for selection of women suitable for waterbirth and for neonatal observation are maintained to reduce the risks to both mothers and babies. The results remain to be tested in a randomized case control study to compare water and ‘dry-land’ birth.
Article
In recent years it became increasingly apparent that women accessing services at Corbar Birth Centre in the High Peak wanted the choice of using water for labour and birth. The Birth Centre responded by undertaking a large project, which resuited in practice deveiopment and the introduction of a permanent birthing pool. Clinicai audit was implemented to evaluate the new service and assess the perceived risks and benefits of immersion in water during labour and birth on specific outcomes. This article describes how the project evolved and aims to share the findings from the March 2001 to April 2004 audits comparing 'pool users' with 'pool births' and reflects on the experience of the midwives.
Article
Introduction: Despite a growing body of evidence for waterbirth safety, a myriad of political and cultural issues result in limited use in US hospitals compared to other developed nations. The purpose of this article is to critically analyze the evidence on maternal and neonatal outcomes of waterbirth to help inform evidence-based clinical practice in the United States. Methods: A literature search was performed using electronic databases CINAHL, Ovid MEDLINE, PubMed, EMBASE, and PsycINFO. Thirty-eight studies, including 2 randomized controlled trials and 36 observational studies, were reviewed. Studies were conducted in 11 countries, mostly outside the United States. More than 31,000 waterbirths were described. Results: Aggregate results suggest that waterbirth is associated with high levels of maternal satisfaction with pain relief and the experience of childbirth, and may increase the likelihood of an intact perineum. Waterbirth is associated with decreased incidence of episiotomy and severe perineal lacerations, and may contribute to reduced postpartum hemorrhage. Data indicate no difference in maternal or neonatal infection rates or nursery admissions after waterbirth. Neonatal mortality rates are low and similar after waterbirth and uncomplicated conventional birth. The calculated cord avulsion rate is 2.4 per 1000 waterbirths; it is unknown how this compares to conventional birth due to a lack of data that permits direct comparison. Discussion: The majority of waterbirth research to date is observational and descriptive; thus, reported outcomes do not demonstrate causal associations. However, existing evidence is reassuring. Case-controlled studies have included thousands of women who gave birth underwater without an apparent increase in maternal or neonatal morbidity or mortality. Potential risks associated with waterbirth for women and neonates appear minimal, and outcomes are comparable to those expected in any healthy childbearing population.
To determine potential risks and/or benefits of underwater birth for mother and infant. The PubMed, Cochrane Library, EMBASE, and CINAHL online databases were searched for relevant English language articles related to research about underwater birth published from 1966 to April 2013. Reference lists of articles retrieved were reviewed to identify additional potentially pertinent publications. Two randomized controlled trials comparing underwater birth to traditional birth ("on land") were identified and served as the primary focus of the analysis. One systematic review of water immersion during labor and birth, one systematic review of neonatal risks of underwater birth, and case reports of neonatal morbidity after underwater birth were also identified. Guidelines regarding underwater birth from professional organizations were reviewed. Data from the two randomized controlled trials were extracted and organized under the following headings: author, year, setting, country, study design, sample size, participants, outcomes, findings and comments. Systematic reviews, case reports, and guidelines from professional organizations were summarized. Research findings and guidelines from professional associations were evaluated regarding potential risks and benefits of underwater birth to the mother and infant. Only two randomized controlled trials comparing underwater birth to birth on land have been published. Results suggest minimal benefit of underwater birth to the mother and no benefit to the infant. Both studies were underpowered to adequately evaluate risk of neonatal harm; however, a number of cases of neonatal morbidity have been reported. Based on these findings, underwater birth requires more rigorous study. In the United States, underwater birth is not supported by the American Academy of Pediatrics or the American College of Obstetricians and Gynecologists outside the context of a randomized controlled trial.
Article
As scant information is present about the effect of water birth on newborns, we aimed to detect the fetal outcomes of water birth. A hundred and ninety one among totally 220 newborns who were born by water birth were enrolled. The demographic and clinical features of the patients, birth complications, infection rates and rates of neonatal intensive care unit attendance were evaluated. The mean gestational week and birth weight were 39.2±1.3 weeks and 3326±409 g. 26% of the mothers was primiparous. Birth trauma was observed in three patients (1.6%) as one brachial nerve paralysis, one cord rupture and one cephal hematoma. Six of the patients (3.1%) were admitted to neonatal intensive care unit (NICU); four of whom had respiratory tract problems. Water birth is a safe method of delivery for the neonates when certain criteria are met.
Article
A cohort study was conducted with a random sample of 33 healthy infants evaluated at birth and at 1, 2, 3, 4, 5, 6, 9, and 12 months to determine the frequency of respiratory rate changes in response to air blown over the face (diving reflex) in the first year of life, and to standardize the description of diving reflex occurrence. All 33 infants remained neurologically normal throughout follow-up. Diving reflex was observed in 95.3% of newborns and in 100% of infants between 2 and 6 months of age. At 6 months, it started to decrease but persisted in 90% of the infants up to 12 months. The diving reflex is highly prevalent in the first year of life and can be easily elicited by applying a flow of air over the infant's face, particularly during crying.
Article
Benefits attributed to waterbirth (WB) include a shorter second stage of labour and reduction of perineal trauma. The aim of this study is to assess the incidence of perineal trauma and pelvic floor function following WB compared to land birth (LB). We conducted a retrospective analysis on the incidence of perineal trauma following a spontaneous WB (n=160) or a LB (n=623). Data were collected using the hospital's healthcare database, which codes information on pregnancy outcomes and related variables. ICIQ-VS for vaginal symptoms, and the ICIQ-KH Long Form (KHQ) were used to assess pelvic floor function a year after delivery. Length of 2nd stage was significantly shorter in the WB group. Although this did not translate into less perineal trauma, the incidence of 3rd degree tears appeared to be doubled in the WB group. 77 (38.5%) women from the WB group and 54 (22%) from the LB group answered the postal questionnaires. A significant number of women reported vaginal and urinary symptoms, however the difference between both groups was not statistically significant. Waterbirth results in a shorter 2nd stage of labour. This does not lead to less overall perineal trauma or better pelvic floor performance postpartum. Physical limitations in protecting the perineum during the expulsion phase may be associated with an increase in the incidence of 3rd degree tears in the WB population.
Article
To assess the cost-effectiveness of water compared with normal land delivery. A retrospective controlled study was conducted over a two-year period in a Northern Italian hospital. The cohort included all the 110 women who completed a water birth and 110 women who had a land birth during the same period. The two groups were compared with respect to labour duration, perineal tear and newborn's health status. The economic evaluation adopted a cost-effectiveness approach in relation to presence/absence of perineal tears. In the water delivery group 58 women (52.7%) experienced at least one perineal tear versus 80 (72.7%) in the traditional delivery group. The mean duration of labour was similar in the two groups. Neonatal well-being, expressed as Apgar score, did not differ significantly among the two groups at the first minute (9.48 vs. 9.28) and was slightly higher at 5 minutes in the water delivery group (9.95 vs. 9.84; P = 0.0269). Water delivery was found to be both more costly [ΔC = €279; 95% confidence interval (CI): 262-296] and more effective in terms of avoided perineal tears. The incremental health care cost per avoided perineal tear because of water delivery was estimated of €1395.7 (95% CI: 1049.2-3608.5). Water birth, as compared with traditional delivery, allows for an increase in maternal well-being and is cost-effective.
Article
This study investigated the experience and perceptions of Georgia certified nurse-midwives about waterbirth and their level of support for establishing waterbirth in their work setting. A survey was distributed to a convenience sample of 119 certified nurse-midwives from the American College of Nurse Midwives, Georgia chapter; 45% of those surveyed responded. The majority of midwives had some exposure to waterbirth through self-education or through clinical practice. More than half supported the incorporation of waterbirth in their workplace setting. Maternal relaxation and reduced use of analgesia were perceived as the greatest benefit of waterbirth. Of 11 items related to disadvantages of waterbirth, certified nurse-midwives were moderately to severely concerned about none. The most concerning factors, with a mean of 2.4 to 2.5 on a scale of 1 (no worry) to 5 (severe worry), were maintenance of water temperature, physical stress on the midwife, and inability to see the perineum. Midwives' support for waterbirth focused mostly on the perceived benefits to the mother with little worry about the risks.
Article
The use of birthing pools during labour is increasing in the United Kingdom. This is without good scientific evidence of their efficacy or safety. To further investigate the value and safety of intrapartum hydrotherapy, an historical cohort study was performed in a District General Hospital in Liverpool. The study group consisted of 100 women of low obstetric risk who used the birthing pool at some stage during their labours and the control group consisted of 100 women who were matched in terms of age, parity and obstetric history but laboured and delivered in air. The main outcome measures were operative delivery rates, duration of labour, analgesic requirements, perineal trauma and Apgar scores at 1 and 5 minutes. The results showed that nulliparas who used the birthing pool had significantly reduced operative delivery rates, a shorter second stage of labour, reduced analgesic requirements and a lower incidence of perineal trauma. In multiparas there were significant reductions in analgesic requirements.
Article
The aim of this study was to document the practice of water births and compare their outcome and safety with normal vaginal deliveries. A retrospective case-control study was conducted over a five year period from 1989 to 1994 at the Maternity Unit, Rochford Hospital, Southend, UK. Three hundred and one women electing for water births were compared with the same number of age and parity matched low risk women having conventional vaginal deliveries. Length of labour; analgesia requirements; apgar scores; maternal complications including perineal trauma, postpartum haemorrhages, infections; fetal and neonatal complications including shoulder dystocias; admissions to the Special Care Baby Unit, and infections were noted. Primigravidae having water births had shorter first and second stages of labour compared with controls (P<0.05 and P<0.005 respectively), reducing the total time spent in labour by 90 min (95% confidence interval 31 to 148). All women having water births had reduced analgesia requirements. No analgesia was required by 38% (95% confidence interval 23.5 to 36.3, P<0.0001) and 1.3% requested opiates compared to 56% of the controls (95% confidence interval 46. 3 to 58.1, P<0.0001). Primigravidae having water births had less perineal trauma (P<0.05). Overall the episiotomy rate was 5 times greater in the control group (95% confidence interval 15 to 26.2, P<0.0001), but more women having water births had perineal tears (95% confidence interval 6.6 to 22.6, P<0.001). There were twice as many third degree tears, post partum haemorrhages and admissions to the Special Care Baby Unit in the controls, although these differences were not significant. Apgar scores were comparable in both groups. There were no neonatal infections or neonatal deaths in the study. This study suffers from many of the methodological problems inherent in investigation of uncommon modes of delivery. However, we conclude that water births in low risk women delivered by experienced professionals are as safe as normal vaginal deliveries. Labouring and delivering in water is associated with a reduction in length of labour and perineal trauma for primigravidae, and a reduction in analgesia requirements for all women.
Article
Waterbirths were introduced in 1991 as part of a new birth concept which consisted of careful monitoring and birth management, restrictive use of invasive methods and free choice of different birth methods. After the introduction of this new birth concept a prospective observational study was initiated. All parturients of the region give birth in our clinic without preselection, ours being the only birth clinic of the region. 2% of the parturients will be referred to a larger birth clinic (university clinic) mainly because of preterm births before the end of the 33rd week of pregnancy. Every one of the 7,508 births between November 1991, and May 21, 1997, was analyzed. In this article the birth parameters of mother and child in the most often chosen spontaneous birth methods will be compared to assess the safety of alternative birth methods in general and of waterbirths in particular. 2,014 of these 5,953 spontaneous births were waterbirths, 1,108 were Maia-birthing stool births and 2,362 bedbirths (vacuum extractions not included). The parity and age of the mother as well as the newborn's birth weight are comparable in all 3 groups: waterbirth, Maia-birthing stool, and bedbirths. An episiotomy was performed in only 12.8% of the births in water, in 27. 7% of the births on the Maia-birthing stool and in 35.4% of the bedbirths. These differences are statistically significant. In spite of the highest episiotomy rates, the bedbirths also show the highest 3rd- and 4th-degree laceration rates (4.1%), thus the difference between the rates for bedbirths and alternative births methods for severe lacerations is significant. The mothers' blood loss is the lowest in waterbirths. Fewer painkillers are used in waterbirths and the experience of birth itself is more satisfying after a birth in water. The average arterial blood pH of the umbilical cord as well as the Apgar scoring at 5 and 10 min are significantly higher after waterbirths. Infections of the neonate do not occur more often after waterbirths. No case of water aspiration or any other perinatal complication of the mother or child which might be water-related was reported. Waterbirths and other alternative forms of birthing such as Maia-birthing stool do not demonstrate higher birth risks for the mother or the child than bedbirths if the same medical criteria are used in the monitoring as well as in the management of birth.
Article
High quality research evidence for nursing practice is available from the Cochrane Library and in clinical practice guidelines produced by professional associations. The transfer of research evidence into practice is a complex process, and changing provider behavior is a challenge, even when the relative advantages are strong. An active approach with multifaceted interventions based on the assessment of barriers has been found most effective. An array of interventions for implementing research findings in practice is included, and promising organizational and theoretical perspectives on increasing the use of research evidence for nursing practice are described.
Article
Five birthing centres were approached for permission to administer a questionnaire, giving a sample of 189 mothers who had experienced waterbirth. Mothers who had Apgars lower than 7 at 1 were excluded from the sample for ethical reasons. The results showed that waterbirth is a consumer-led trend, mainly pursued by educated middle class women. Better antenatal preparation is needed to reduce the need for other forms of analgesia when women are in water. Most women desired waterbirth as they thought it was a natural drug-free method and would be a less painful birth. They also wanted a gentle delivery for the baby and thought waterbirth seemed the right medium for this. They felt more in control of their environment in water, and particularly liked the relaxing calming quality of the water, the physical support it gave them and being able to hold their babies immediately after birth. Women's responses to the survey suggested that mothers perceived waterbirth as therapeutic. They demonstrated a strong desire for water in labour. There were no significant behaviour differences between water-born babies and non water-born babies.
Article
Our purpose was to assess benefits and possible disadvantages of water births and to compare maternal and neonatal outcomes with normal vaginal deliveries. This case-controlled study was carried out between January 2000 and July 2001. A total of 140 women who wanted water births were enrolled into the study. Our analysis was restricted to a sample of women with a gestational age > 37 weeks, a normal sized foetus, a reactive admission cardiotocography, drainage of clear amniotic fluid (if the membranes were already ruptured) and a pregnancy with cephalic presentation. Women with medical or obstetric risk factors were excluded. 140 controls were selected from the delivery database as the next parity-matched normal spontaneous vaginal delivery. A statistically significant lower rate of episiotomies (p = 0.0001) and vaginal trauma (p = 0.03) was detected in the group assigned to water birth, whereas the frequency of perineal tears and labial trauma remained similar in both groups (p > 0.05). A statistically significant decrease in the use of medical analgesia (p = 0.0001) and oxytocin (p = 0.002) was observed in women who had water births. A trend towards a reduction of the length of the first stage of labour was only observed in primiparous women bearing in water, but this reduction did not reach statistically significance (p > 0.05). Manual placenta removal (p = 0.017), severe postpartum haemorrhage (blood loss > 500 ml; p = 0.002) and maternal infection rate (p = 0.03) were statistically significant lower in women who delivered in water. When analysing the postpartum haemoglobin, no statistically significant differences could be observed between the two groups (p > 0.05). No statistically significant differences were detected for neonatal parameters (p > 0.05) between women who had had water births and those choosing conventional vaginal delivery.
Article
The risk of infectious complications after water birth which might be due to water contaminated by faecal bacteria or environmental microbes from the water supply system is still in discussion. We performed a microbiological study comparing neonatal bacterial colonisation after water birth to conventional bed deliveries with or without relaxation bath. In all three groups (96 deliveries) we isolated most frequently from ear and palate of the newborns Staphylococcus epidermidis, E. coli and enterococci, which belong to the normal vaginal flora. Neonatal outcome, infantś and maternal infection rate did not differ between the three groups.
Article
We performed a retrospective review of the literature on the complications that could be associated potentially with water birth. We performed an extensive review of the medical literature using the Pub Med search engine, which is available through the National Library of Medicine. We also examined the Cochrane review on immersion in pregnancy, labor and birth. Our review revealed 74 articles regarding water births. We found 16 citations that described complications that were associated with underwater birth. Possible complications that were associated with water birth included fresh water drowning, neonatal hyponatremia, neonatal waterborne infectious disease, cord rupture with neonatal hemorrhage, hypoxic ischemic encephalopathy, and death. Our systematic review did not identify an adequately controlled trial of delivery underwater (second stage of labor underwater) compared with delivery in air. Water birth may be associated with potential complications that are not seen with land-based birth. The rates of these complications are likely to be low but are not well defined.
Article
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. A randomised controlled trial (RCT) with 'preference arm'. District general hospital with 3600 deliveries annually. Women with no pregnancy complications and no anticipated problems for labour/delivery. 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. 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. 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. This small study has shown that a RCT is feasible and demonstrated outcome measures, which can be successfully collected in an average delivery suite.
Article
We reviewed 1600 water births at a single institution over an 8-year period. 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. 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). 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.
Article
The goal of our study was to assess the effect of water birth on obstetrical outcome, the maternal and neonatal infection rate in a selected low risk collective. In this prospective observational study (1998-2002) 513 women, wished to have a water birth. The study was approved by the local ethical committee, informed consent was obtained. According to the course of delivery, we compared three groups: woman who had a water birth, a normal vaginal delivery after immersion and a normal vaginal delivery without immersion. Outcome measurements were maternal and fetal infection rate, obstetrical outcome parameters and relevant laboratory parameters. The groups were comparable in terms of demographic and obstetric data. The maternal and neonatal infection rate and laboratory parameters showed no significant difference among the groups. There was no maternal infection related to water birth. There were five water born neonates and three neonates after normal vaginal delivery preceded by immersion with conjunctivitis. Significant differences were observed in obstetrical outcome parameters: less use of analgesia, shorter duration of first and second stage of labor, smaller episiotomy rate in water birth. In contrast no differences were seen in all observed fetal outcome parameters: APGAR score, arterial and venous pH, admission rate to neonatal intensive care unit. Water birth is a valuable alternative to traditional delivery. The maternal and fetal infection rate was comparable to traditional deliveries. A careful selection of a low risk collective is essential to minimize potential risks.
Article
The aim of the study is to analyse urethral mobility and excursion of the pubo-rectal angle, using perineal ultrasound, after normal vaginal delivery and water delivery. A total of 52 primiparous women were enrolled: 25 who had delivery in water (W Group), 27 who had delivery without using water (NW Group). Every woman underwent perineal ultrasound assessment at 6 months after having given birth. The following parameters were assessed: urethral mobility during Valsalva's manoeuvre, movement of the puborectal sling angle during contraction of the levator ani muscle. Data obtained show that the urethral mobility during Valsalva's manoeuvre is higher in the W Group (34.9 degrees) in comparison to the NW Group (29.5 degrees), without statistically significant differences. The excursion of the pubo-rectal sling angle resulted lower in the W Group (8.7 degrees) than in the NW Group (11.0 degrees), without statistically significant differences. The present study found no statistically differences in pelvic floor, using perineal ultrasound, between water and "non-water" delivery.
UK: Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives
  • Sussex Place
  • London
Sussex Place, London, UK: Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives; 2006. 50.
Water birth and perineal dysfunctions: Prospective study
  • G Torrisi
  • Giuseppe E Fonti
  • I Ferraro
  • D 'urso
  • E Guardabasso
Torrisi G, Giuseppe E, Fonti I, Ferraro S, D'Urso E, Guardabasso V. Water birth and perineal dysfunctions: Prospective study. Neurourol Urodyn. 2010;29(S2):89-91.