Outcomes of Waterbirth in a US Hospital-Based Midwifery Practice: A Retrospective Cohort Study of Water Immersion During Labor and Birth

Association Between Hydrotherapy During Labor and β-Endorphin Levels in Postpartum Mother's Milk

BACKGROUND

Hydrotherapy is a complementary and alternative method in childbirth widely used to reduce labor pain and stress. The birth process significantly influences levels of β-endorphin in human milk. However, the relationship between hydrotherapy during labor and β-endorphin levels in the mother's milk is unclear.

AIMS

We aimed to investigate the relationship between hydrotherapy during labor, and human milk β-endorphin levels. The study also aimed to investigate the relationship between milk β-endorphin levels and maternal labor pain and birth satisfaction.

METHOD

We conducted a cross-sectional observational study involving a total of 84 participants who gave birth vaginally. Among them, 42 received hydrotherapy during the initial stage of labor, while the remaining 42 did not. Considering the available data, an alpha of 0.05 (Type I error), and β-endorphin concentration, our sample of 84 participants provided a power calculation of 65%. Milk samples were collected, and the Perception of Birth Scale was administered 24 hours after birth. The concentration of β-endorphin in the participant's milk and the Perception of Birth Scale were compared using Mann-Whitney U tests.

RESULTS

The amount of β-endorphin in milk was higher for participants who received hydrotherapy than for those who did not (Mean = 503.5 pg/ml, SD = 569.2; mean = 295.7 pg/ml, SD 274 respectively; p = 0.028). The total Perception of Birth Scale scores were higher in the hydrotherapy group compared to the control group (Mean = 78.9, SD = 6.2; mean = 74.1, SD = 6.4; p = 0.001).

CONCLUSIONS

Hydrotherapy is correlated with a positive perception of birth and higher levels of β-endorphin in milk. Further research on the causal relationship between hydrotherapy and β-endorphin levels in milk may support its use to facilitate positive changes in mother's milk.

The Effect of Hydrotherapy Application on Pain During Birth and Postpartum Fatigue and Comfort

BACKGROUND

The aim of this study is to investigate the effect of hydrotherapy applied during labour on pain felt at birth, postpartum fatigue and comfort, and person-centred maternity care.

METHODS

The sample of this randomized controlled experimental study consisted of 80 pregnant women (40 in the experimental group and 40 in the control group) who would give a birth for the second time. The experimental group was given a shower twice with water at 32°C-37°C in the desired position for 20 min when the dilation was 4-5 cm and 6-8 cm. The control group was given routine care. Data were collected with a descriptive information form and the Visual Analogue Scale (VAS) before the birth and with the Visual Analogue Scale for Fatigue (VASF), the Postpartum Comfort Scale (PCS), and the Person-Centred Maternity Care Scale (PCMCS) following the birth. Pearson's χ2 test, independent samples t-test and Mann-Whitney U test were used to analyze the data, and the confidence interval was evaluated at p < 0.05.

RESULTS

The labour times, VAS values and VASF scores of the hydrotherapy group were significantly lower than those of the control group (VAS: 6.98 ± 1.46; 9.45 ± 0.68; VASF: 59.43 ± 36.33; 76.47 ± 26.91, respectively). The hydrotherapy group had significantly higher 1st- and 5th-minute Apgar scores, postpartum comfort scores and PCMCS scores than the control group (PCS: 138.4 ± 15.62; 135.35 ± 10.84; PCMCS: 59.35 ± 5.32; 58.55 ± 4.11, respectively).

CONCLUSION

It was determined that hydrotherapy application shortened labour time, had a positive effect on newborn Apgar scores, relieved pain felt during birth, reduced postpartum fatigue, increased postpartum comfort and had a positive effect on person-centred maternal care.

Effects of Water Immersion Versus Epidural as Analgesic Methods during Labor among Low-Risk Women: A 10-Year Retrospective Cohort Study

BACKGROUND

Adequate pain relief during childbirth is a very important issue for women and healthcare providers. This study investigates the effects on maternal and neonatal outcomes of two analgesic methods during labor: water immersion and epidural analgesia.

METHODS

In this retrospective observational cohort study at a first-level hospital, in Spain, from 2009 to 2019, 1134 women, low-risk singleton and at term pregnancy, were selected. Among them, 567 women used water immersion; 567 women used epidural analgesia for pain control. Maternal outcomes included mode of birth and perineum condition. Neonatal outcomes included 5 min Apgar score, umbilical cord arterial pH, and Neonatal Intensive Care Unit admissions. Chi-square tests and Mann-Whitney U tests, together with their effect sizes (Cramer's V, odds ratio, and Cohen's d) were used to test the main hypotheses.

RESULTS

Spontaneous vaginal birth was almost 17 times more likely in the water immersion group (OR = 16.866 [6.540, 43.480], p < 0.001), whereas the odds of having a cesarean birth were almost 40 times higher in the epidural group (OR = 39.346 [3.610, 429.120], p < 0.001). The odds of having an intact perineum were more than two times higher for the water immersion group (OR = 2.606 [1.290, 5.250], p = 0.007), whereas having an episiotomy was more than eight times more likely for the epidural group (OR = 8.307 [2.800, 24.610], p < 0.001). Newborns in the water immersion group showed a better 5 min Apgar score and umbilical cord arterial pH and lower rates in admissions at the Neonatal Intensive Care Unit.

CONCLUSIONS

Women choosing water immersion as an analgesic method were no more likely to experience adverse outcomes and presented better results than women choosing epidural analgesia.

[Influence of water immersion on the use of epidural anesthesia during labor]

OBJECTIVE

Immersion in water during labor could reduce pain and use of epidural anesthesia during childbirth. The main objective of this study was to evaluate the influence of immersion in water during labor on the use of epidural anesthesia in a midwife care setting.

METHODS

We conducted a single-center retrospective study of all women who gave birth in the physiological ward of Saint-Étienne University Hospital between October 2020 and December 2022.

RESULTS

The study did not find difference between immersion group and control group concerning the use of epidural anesthesia (P=0.49). The immersion group counted more women with a duration of labor greater than 6hours than in the control group. The multivariate analysis adjusted for parity and duration of labor did not find difference between both groups [OR 0.58; 95% CI (0.30; 1.09)].

CONCLUSION

Even if it does not seem to modify the use of epidurals, immersion in water does not seem to increase maternal and neonatal morbidity and mortality. It represents a therapeutic alternative with reasonable cost to offer for pregnant women who wish to give birth without epidural anesthesia.

Influence of non-pharmacological methods on duration of labor: a systematic review

The article aims to verify the influence of MNFs on the duration of the birth process. A systematic review was carried out in the MEDLINE, Web of Science and LILACS databases, through a combination of terms that cover the topic addressed, from 1996 to 2021/April. The Excel spreadsheet was used to collect data to extract information regarding each selected article, in turn, data analysis included the evaluation and classification of quality, reliability and risk of bias, thus, the following tools were used: Cochrane RoB 2, Checklist and Newcastle-Ottawa Scale. Warm bath, walking, exercises with a birthing ball, breathing techniques, supine position, acupuncture, acupressure and water birth reduced labor time. While spontaneous pushing, massage and immersion baths prolonged labor. Non-pharmacological methods capable of reducing the duration of labor were hot/warm shower, walking, birth ball exercises, breathing techniques, maternal mobility, dorsal position, acupuncture, acupressure and water birth, as well. associated applied techniques such as hot/warm bath, ball exercises and lumbosacral massage, as well as immersion bath, ball exercises, aromatherapy, vertical postures and maternal mobility with alternating vertical postures, shortened the birth time.

Water birth: a systematic review and meta-analysis of maternal and neonatal outcomes

OBJECTIVE

This systematic review and meta-analysis aimed to conduct a thorough and contemporary assessment of maternal and neonatal outcomes associated with water birth in comparison with land-based birth.

DATA SOURCES

We conducted a comprehensive search of PubMed, EMBASE, CINAHL, and gray literature sources, from inception to February 28, 2023.

STUDY ELIGIBILITY CRITERIA

We included randomized and nonrandomized studies that assessed maternal and neonatal outcomes in patients who delivered either conventionally or while submerged in water.

METHODS

Pooled unadjusted odds ratios with 95% confidence intervals were calculated using a random-effects model (restricted maximum likelihood method). We assessed the 95% prediction intervals to estimate the likely range of future study results. To evaluate the robustness of the results, we calculated fragility indices. Maternal infection was designated as the primary outcome, whereas postpartum hemorrhage, perineal lacerations, obstetrical anal sphincter injury, umbilical cord avulsion, low Apgar scores, neonatal aspiration requiring resuscitation, neonatal infection, neonatal mortality within 30 days of birth, and neonatal intensive care unit admission were considered secondary outcomes.

RESULTS

Of the 20,642 articles identified, 52 were included in the meta-analyses. Based on data from observational studies, water birth was not associated with increased probability of maternal infection compared with land birth (10 articles, 113,395 pregnancies; odds ratio, 0.93; 95% confidence interval, 0.76-1.14). Patients undergoing water birth had decreased odds of postpartum hemorrhage (21 articles, 149,732 pregnancies; odds ratio, 0.80; 95% confidence interval, 0.68-0.94). Neonates delivered while submerged in water had increased odds of cord avulsion (10 articles, 91,504 pregnancies; odds ratio, 1.75; 95% confidence interval, 1.38-2.24) and decreased odds of low Apgar scores (21 articles, 165,917 pregnancies; odds ratio, 0.69; 95% confidence interval, 0.58-0.82), neonatal infection (15 articles, 53,635 pregnancies; odds ratio, 0.64; 95% confidence interval, 0.42-0.97), neonatal aspiration requiring resuscitation (19 articles, 181,001 pregnancies; odds ratio, 0.60; 95% confidence interval, 0.43-0.84), and neonatal intensive care unit admission (30 articles, 287,698 pregnancies; odds ratio, 0.56; 95% confidence interval, 0.45-0.70).

CONCLUSION

When compared with land birth, water birth does not appear to increase the risk of most maternal and neonatal complications. Like any other delivery method, water birth has its unique considerations and potential risks, which health care providers and expectant parents should evaluate thoroughly. However, with proper precautions in place, water birth can be a reasonable choice for mothers and newborns, in facilities equipped to conduct water births safely.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Systematic Reviews and Synthesis without Meta-Analysis on Hydrotherapy for Pain Control in Labor

BACKGROUND

Although there is scientific evidence regarding the use of water immersion during labor, this evidence is primarily focused on the first stage of labor. There is limited scientific evidence on water immersion during the second stage of labor.

OBJECTIVE

The objective of this study was to conduct a comprehensive systematic review and synthesis of contemporary evidence related to water birth, with a specific focus on the second stage of labor.

METHODS

A systematic review of the scientific literature published between January 2018 and October 2023 was carried out. A synthesis of the results was conducted following the Synthesis without Meta-Analysis (SWiM) guidelines. PubMed, Scopus, and the Cochrane Library were utilized as information sources. The search strategy was designed using the keywords "immersion" and "parturition", along with their relevant synonyms. Inclusion criteria encompassed studies employing randomized controlled trials (RCTs), systematic reviews, and quantitative and qualitative approaches focusing on pregnant women undergoing water immersion at any stage of the labor process.

RESULTS

Eleven articles were selected: two systematic reviews (one quantitative and one qualitative), five cohort studies, one case-control study, one cross-sectional observational study, and two qualitative studies. A thorough assessment of the methodology was performed using several specific tools: the Cochrane RoB 2 (Risk of Bias 2) tool for systematic reviews, JBI Critical Appraisal Checklist for Qualitative Research for qualitative studies, STROBE for observational descriptive studies, and CASPe for qualitative studies. The results provided fundamental insights that will contribute to conceptual standardization regarding the effects of water birth on maternal and fetal health. Additionally, a synthesis of the results was performed concerning types of delivery, analgesia use, pain perception, and maternal satisfaction with the water birth experience.

CONCLUSIONS

In this study, we conclude that the results regarding delivery types, labor durations, and analgesia use found in the literature, along with statistically significant maternal/fetal effects, are crucial for making recommendations regarding the use of water during labor in any of its stages if the woman desires it safely.

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

Background

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

Objectives

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

Methods

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

Results

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

Conclusion

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

Alternate Birth Strategies

Community birth is defined as birth that occurs outside the hospital setting. Birthing in a birth center can be safe for certain patient populations. Home birth can also be safe in well-selected patient with a well-established transfer infrastructure should an emergency occur. Unfortunately, many areas of the United States and the world do not have this infrastructure, limiting access to safe community birth. Immersion during labor has been associated with decreased need for epidural and pain medication. Delivery should not occur in water due to concerns for infection and cord avulsion. Umbilical cord non-severance (also called lotus birth) and placentophagy should be counseled against due to well-documented risks without clear benefit. Birth plans and options should be regularly discussed during pregnancy visits.

Neonatal outcomes after water birth: A retrospective cohort study

OBJECTIVE

To compare neonatal outcomes between water births, births with immersion only during labour, and births in which immersion was never used.

METHODS

A retrospective cohort study was performed including mother-baby dyads attended between 2009 and 2019 at the Hospital do Salnés regional hospital (Pontevedra, Spain). These women were categorised into 3 groups: water birth; immersion only during dilation; and women who never used immersion. Several sociodemographic-obstetric variables were studied and the main outcome was the admission of the neonate to the intensive care unit (NICU). Permission was obtained from the responsible provincial ethics committee. Descriptive statistics were used and between-group comparisons were performed using variance for continuous variables and chi-square for categorical variables. Multivariate analysis was performed with backward stepwise logistic regression and incidence risk ratios with 95%CI were calculated for each independent variable. Data were analysed using IBM SPSS® statistical software.

RESULTS

A total of 1191 cases were included. 404 births without immersions; 397 immersions only during the first stage of labor; and 390 waterbirths were included. No differences were found in the need to transfer new-borns to a NICU (p = .735). In the waterbirth cohort, neonatal resuscitation (p < .001, OR: 0,1), as well as respiratory distress (p = .005, OR: 0,2) or neonatal problems during admission (p < .001, OR: 0,2), were lower. In the immersion only during labor cohort, less neonatal resuscitation (p = .003; OR: 0,4) and respiratory distress (p = .019; OR: 0,4) were found. The probability of not breastfeeding upon discharge was higher for the land birth cohort (p < .001, OR: 0,4).

CONCLUSIONS

The results of this study indicated that water birth did not influence the need for NICU admission, but was associated with fewer adverse neonatal outcomes, such as resuscitation, respiratory distress, or problems during admission.

Content Analysis of Water Birth Policies With Implications for Practice and Research

OBJECTIVE

To identify areas of agreement and variation in clinical guidance documents (protocols, policies, or guidelines) that direct water birth care.

DESIGN

Qualitative descriptive.

SETTING

The clinical guidance documents studied covered water birth in home and hospital settings.

SAMPLE

The sample included 22 water birth guidance documents in English from six countries. The documents were obtained by request and resulting snowball sampling.

MEASUREMENTS

The framework method was adapted as an analytic tool, and a structured matrix output was used to organize and support the method of qualitative content analysis using a general inductive approach. Areas of general agreement and variations in practice guidelines for water birth were identified.

RESULTS

Criteria for a term, singleton, and cephalic presentation with reassuring maternal and fetal status were the most consistent for inclusion. The reliance on "low-risk" status was strongly present but without a uniform definition. A history of previous cesarean birth, body mass index, use of opioid pain medication, adequate labor progress, and vaginal bleeding were found to vary in directed care, and scarce supporting evidence was offered. Meconium-stained fluid variably excluded water birth in most documents, but this was not supported by evidence. The inconsistent findings from this study are cohesive in the evidence they provide for needed research in areas that affect access to water birth. The findings also provide nurses and birth providers with evidence-based guidelines for water birth care.

CONCLUSION

There was variation across guidance documents, demonstrating that water immersion is a flexible intervention that can be implemented in different settings and locations while following individual facility protocols for processes for care. An identified area of concern comes from examples of overly restrictive policies for water birth based on opinion or perceived risk rather than evidence from research.

A prospective cohort study comparing neonatal outcomes of waterbirth and land birth in an Australian tertiary maternity unit

BACKGROUND

Maternal preference for warm water immersion (WWI) and waterbirth is increasing, but adoption into obstetric guidelines and clinical practice remains limited. Concerns regarding safety and a paucity of evidence have been cited as reasons for the limited adoption and uptake.

AIM

The aim was to investigate maternal and neonatal outcomes after WWI and/or waterbirth compared with land birth.

MATERIALS AND METHODS

A prospective cohort study was conducted in an Australian public maternity hospital between 2019 and 2020. Maternal and neonatal outcomes for 1665 women who had a vaginal birth were studied. Primary outcome was admission to the neonatal unit (NNU). Secondary outcomes included neonatal antibiotic administration, maternal intrapartum fever, epidural use and perineal injury. Multivariate logistical regression analyses compared the outcomes between three groups: waterbirth, WWI only and land birth.

RESULTS

NNU admissions for a suspected infectious condition were significantly higher in the land birth group (P = 0.035). After accounting for labour duration, epidural use and previous birth mode, no significant difference was detected between groups in the odds of NNU admission (P = 0.167). No babies were admitted to NNU with water inhalation or drowning. Women birthing on land were more likely to be febrile (2 vs 0%; P = 0.007); obstetric anal sphincter injury and postpartum haemorrhage were similar between groups. Regional analgesia use was significantly lower in the WWI group compared to the land birth group (21.02 vs 38.58%; P = <0.001). There was one cord avulsion in the waterbirth group (0.41%).

CONCLUSION

Maternal and neonatal outcomes were similar between groups, with no increased risk evident in the waterbirth and WWI groups.

Is a randomized controlled trial of waterbirth possible? An Australian feasibility study

BACKGROUND

The safety of waterbirth is contested because of the lack of evidence from randomized trials and conflicting results. This research assessed the feasibility of a prospective study of waterbirth (trial or cohort).

METHODS

We conducted a prospective cohort study at an Australian maternity hospital. Eligible women with uncomplicated pregnancies at 36 weeks of gestation were recruited and surveyed about their willingness for randomization. The primary midwife assessed waterbirth eligibility and intention on admission in labor, and onset of second stage. Primary outcomes measured feasibility. Intention-to-treat analysis, and per-protocol analysis, compared clinical outcomes of women and their babies who intended waterbirth and nonwaterbirth at onset of second stage.

RESULTS

1260 participants were recruited; 15% (n = 188) agreed to randomization in a future trial. 550 women were analyzed by intention-to-treat analysis: 351 (waterbirth) and 199 (nonwaterbirth). In per-protocol analysis, 14% (n = 48) were excluded. Women in the waterbirth group were less likely to have amniotomy and more likely to have water immersion and physiological third stage. There were no differences in other measures of maternal morbidity. There were no significant differences between groups for serious neonatal morbidity; four cord avulsions occurred in the waterbirth group with none in the landbirth group. An RCT would need approximately 6000 women to be approached at onset of second stage.

CONCLUSIONS

A randomized trial of waterbirth compared with nonwaterbirth, powered to detect a difference in serious neonatal morbidity, is unlikely to be feasible. A powered prospective study with intention-to-treat analysis at onset of second stage is feasible.

Systematic review and meta-analysis to examine intrapartum interventions, and maternal and neonatal outcomes following immersion in water during labour and waterbirth

OBJECTIVES

Water immersion during labour using a birth pool to achieve relaxation and pain relief during the first and possibly part of the second stage of labour is an increasingly popular care option in several countries. It is used particularly by healthy women who experience a straightforward pregnancy, labour spontaneously at term gestation and plan to give birth in a midwifery led care setting. More women are also choosing to give birth in water. There is debate about the safety of intrapartum water immersion, particularly waterbirth. We synthesised the evidence that compared the effect of water immersion during labour or waterbirth on intrapartum interventions and outcomes to standard care with no water immersion. A secondary objective was to synthesise data relating to clinical care practices and birth settings that women experience who immerse in water and women who do not.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

A search was conducted using CINAHL, Medline, Embase, BioMed Central and PsycINFO during March 2020 and was replicated in May 2021.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Primary quantitative studies published in 2000 or later, examining maternal or neonatal interventions and outcomes using the birthing pool for labour and/or birth.

DATA EXTRACTION AND SYNTHESIS

Full-text screening was undertaken independently against inclusion/exclusion criteria in two pairs. Risk of bias assessment included review of seven domains based on the Robbins-I Risk of Bias Tool. All outcomes were summarised using an OR and 95% CI. All calculations were conducted in Comprehensive Meta-Analysis V.3, using the inverse variance method. Results of individual studies were converted to log OR and SE for synthesis. Fixed effects models were used when I2 was less than 50%, otherwise random effects models were used. The fail-safe N estimates were calculated to determine the number of studies necessary to change the estimates. Begg's test and Egger's regression risk assessed risk of bias across studies. Trim-and-fill analysis was used to estimate the magnitude of effect of the bias. Meta-regression was completed when at least 10 studies provided data for an outcome.

RESULTS

We included 36 studies in the review, (N=157 546 participants). Thirty-one studies were conducted in an obstetric unit setting (n=70 393), four studies were conducted in midwife led settings (n=61 385) and one study was a mixed setting (OU and homebirth) (n=25 768). Midwife led settings included planned home and freestanding midwifery unit (k=1), alongside midwifery units (k=1), planned homebirth (k=1), a freestanding midwifery unit and an alongside midwifery unit (k=1) and an alongside midwifery unit (k=1). For water immersion, 25 studies involved women who planned to have/had a waterbirth (n=151 742), seven involved water immersion for labour only (1901), three studies reported on water immersion during labour and waterbirth (n=3688) and one study was unclear about the timing of water immersion (n=215).Water immersion significantly reduced use of epidural (k=7, n=10 993; OR 0.17 95% CI 0.05 to 0.56), injected opioids (k=8, n=27 391; OR 0.22 95% CI 0.13 to 0.38), episiotomy (k=15, n=36 558; OR 0.16; 95% CI 0.10 to 0.27), maternal pain (k=8, n=1200; OR 0.24 95% CI 0.12 to 0.51) and postpartum haemorrhage (k=15, n=63 891; OR 0.69 95% CI 0.51 to 0.95). There was an increase in maternal satisfaction (k=6, n=4144; OR 1.95 95% CI 1.28 to 2.96) and odds of an intact perineum (k=17, n=59 070; OR 1.48; 95% CI 1.21 to 1.79) with water immersion. Waterbirth was associated with increased odds of cord avulsion (OR 1.94 95% CI 1.30 to 2.88), although the absolute risk remained low (4.3 per 1000 vs 1.3 per 1000). There were no differences in any other identified neonatal outcomes.

CONCLUSIONS

This review endorses previous reviews showing clear benefits resulting from intrapartum water immersion for healthy women and their newborns. While most included studies were conducted in obstetric units, to enable the identification of best practice regarding water immersion, future birthing pool research should integrate factors that are known to influence intrapartum interventions and outcomes. These include maternal parity, the care model, care practices and birth setting.

PROSPERO REGISTRATION NUMBER

CRD42019147001.

Maternal and neonatal outcomes following waterbirth: a cohort study of 17 530 waterbirths and 17 530 propensity score-matched land births

OBJECTIVE

Investigate maternal and neonatal outcomes following waterbirth.

DESIGN

Retrospective cohort study, with propensity score matching to address confounding.

SETTING

Community births, United States.

SAMPLE

Medical records-based registry data from low-risk births were used to create waterbirth and land birth groups (n = 17 530 each), propensity score-matched on >80 demographic and pregnancy risk covariables.

METHODS

Logistic regression models compared outcomes between the matched waterbirth and land birth groups.

MAIN OUTCOME MEASURES

Maternal: immediate postpartum transfer to a hospital, any genital tract trauma, severe (3rd/4th degree) trauma, haemorrhage >1000 mL, diagnosed haemorrhage regardless of estimated blood loss, uterine infection, uterine infection requiring hospitalisation, any hospitalisation in the first 6 weeks. Neonatal: umbilical cord avulsion; immediate neonatal transfer to a hospital; respiratory distress syndrome; any hospitalisation, neonatal intensive care unit (NICU) admission, or neonatal infection in the first 6 weeks; and neonatal death.

RESULTS

Waterbirth was associated with improved or no difference in outcomes for most measures, including neonatal death (adjusted odds ratio [aOR] 0.56, 95% CI 0.31-1.0), and maternal or neonatal hospitalisation in the first 6 weeks (aOR 0.87, 95% CI 0.81-0.92 and aOR 0.95, 95% CI 0.90-0.99, respectively). Increased morbidity in the waterbirth group was observed for two outcomes only: uterine infection (aOR 1.25, 95% CI 1.05-1.48) (but not hospitalisation for infection) and umbilical cord avulsion (aOR 1.57, 95% CI 1.37-1.82). Our results are concordant with other studies: waterbirth is neither as harmful as some current guidelines suggest, nor as benign as some proponents claim.

TWEETABLE ABSTRACT

New study demonstrates #waterbirth is neither as harmful as some current guidelines suggest, nor as benign as some proponents claim. @TheUpliftLab @BovbjergMarit @31415926abc @NICHD_NIH.

The Term Newborn: Alternative Birth Practices, Refusal, and Therapeutic Hesitancy

The care of late preterm and term newborns delivered in hospital settings in the United States is largely standardized with many routine interventions and screenings that are evidence-based and serve to protect newborn's and the public's health. Refusals of various aspects of routine newborn care are uncommon but can be challenging for clinicians who care for newborns to navigate for many reasons. In this article, we describe the spectrum of refusal. We review suggested approaches that clinicians can take starting with increasing their own awareness of what specific components of newborn care are refused and why.

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

Background

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

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

Methods

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

Results

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

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

Conclusions

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

Supplementary Information

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

Maternal and Neonatal Outcomes in Hospital-Based Deliveries With Water Immersion

Hospital-based deliveries with second-stage water immersion had no higher risk of neonatal intensive care or special care nursery admissions than a clinically comparable population.

OBJECTIVE:

To compare neonatal intensive care unit (NICU) or special care nursery admission for deliveries with water immersion compared with deliveries in the matched control group without water immersion. Secondary outcomes included adverse neonatal diagnoses, maternal infections, and perineal lacerations.

METHODS:

We conducted a retrospective study using electronic health record data (2014–2018) from two health systems (eight hospitals), with similar clinical eligibility, associated with low risks of intrapartum complications, and implementation policies for waterbirth. The water immersion group included women intending waterbirth. Water immersion was recorded prospectively during delivery. The comparison population were women who met the clinical eligibility criteria for waterbirth but did not experience water immersion during labor. Comparison cases were matched (1:1) using propensity scores. Outcomes were compared using Fischer's exact tests and logistic regression with stratification by stage of water immersion.

RESULTS:

Of the 583 women with water immersion, 34.1% (199) experienced first-stage water immersion only, 65.9% (384) experienced second-stage immersion, of whom 12.0% (70) exited during second stage, and 53.9% (314) completed delivery in the water. Neonatal intensive care unit or special care nursery admissions were lower for second-stage water immersion deliveries than deliveries in the control group (odds ratio [OR] 0.3, 95% CI 0.2–0.7). Lacerations were lower in the second-stage immersion group (OR 0.5, 95% CI 0.4–0.7). Neonatal intensive care unit or special care nursery admissions and lacerations were not different between the first-stage immersion group and their matched comparisons. Cord avulsions occurred for 0.8% of second-stage water immersion deliveries compared with none in the control groups. Five-minute Apgar score (less than 7), maternal infections, and other adverse outcomes were not significantly different between either the first- or second-stage water immersion groups and their control group.

CONCLUSION:

Hospital-based deliveries with second-stage water immersion had lower risk of NICU or special care nursery admission and perineal lacerations than matched deliveries in the control group without water immersion.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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