This prospective, longitudinal study spanning more than 9 years examines the influence of the birthing method, in particular water birth, on neonatal and maternal morbidity and mortality. Using questionnaires, maternal and neonatal data of 9,518 spontaneous singleton births with cephalic presentation, including 3,617 water births and 5,901 land births, were compared. Land births show significantly higher rates of episiotomies as well as third- and fourth-degree perineal tears. Waters births show a significantly higher rate of births 'without injuries', first- and second-degree perineal tears, vaginal and labial tears. The average loss of blood after water birth is -5.26 g/l; this is statistically significantly less than after land births at -8.08 g/l. In 69.7%, water births required no analgesic, compared to 30.3% for land births. Water and land births do not differ with respect to maternal and neonatal infections. After land births, there was a significantly higher rate of newborn complications with subsequent transfer to an external NICU. There were neither maternal nor neonatal deaths related to the birthing event. Water births are just as safe as land births if obstetrical guidelines are followed. Risks, such as preeclampsia, signs of infection, meconium-stained amniotic fluid and pathological CTG, are found more frequently in land births and indicate that a safe and prospective birth management is being followed.
Brazil
Midwifery (June 2009), 25 (3), pg. 286-294 A randomised controlled trial evaluating the effect of immersion bath on labour pain FM Barbosada Silva; SM Junqueira Vasconcellosde Oliveira; M R CuceNobre;Sao Paolo Brazil Abstract Objective: to evaluate the effect of an immersion bath on pain magnitude during the first stage of labour. Design: a randomised controlled trial comparing the pain scores of bathing and non-bathing nulliparous women during birth was employed. Setting: the study was conducted at the Normal Birth Center of Amparo Maternal, São Paulo, Brazil. Participants: 108 birthing women, with 54 women randomly assigned to each group. Interventions: when the birthing women presented at 6–7cm of cervical dilation, they were placed in an immersion bath for 60mins. Outcome measures: pain scores, using a behavioural pain scale and a numeric scale, were recorded at two evaluation time points: at 6–7cm of cervical dilation and 1h after the first pain score evaluation. Findings: at the first evaluation, on the behavioural scale, the means were 2.1 for both groups (p=0.914; 95% confidence intervals (CI) 1.9–2.3 for the control group and 2.0–2.2 for the experimental group). On the numeric scale, the means were 8.7 and 8.5 for the control and experimental groups, respectively (p=0.235; 95% CI 8.2–9.2 for the control group and 8.1–8.9 for the experimental group). At the second evaluation, the pain score means for both scales were statistically higher in the control group than in the experimental group. On the behavioural scale, the scores were 2.4 vs. 1.9, respectively, for the control and experimental groups (p<0.001; 95% CI 2.2–2.6 for the control group and 1.7–2.1 for the experimental group). On the numeric scale, the scores were 9.3 vs. 8.5, respectively, for the control and experimental groups (p<0.05; 95% CI 8.9–9.7 for the control group and 8.1–8.9 for the experimental group). Conclusions: mean labour pain scores in the control group were significantly higher than those in the experimental group. The present findings suggest that use of an immersion bath is a suitable alternative form of pain relief for women during labour.
Pellantová S, Vebera Z, Půcek P., Porodnické a gynekologické oddĕlení, Okresní nemocnice s poliklinikou Znojmo.
Abstract
OBJECTIVES OF STUDY: Comparison of chosen parameters of the I.-III. stage of labour by women, who conducted waterbirth (Group A) and by women, who delivered conventionally in horizontal position (Group B) and comparison of perinatal and postnatal results of newborns in both groups. DESIGN: Retrospective study. SETTING: Department of Obstetrics and Gynecology, District Hospital Znojmo. METHODS: Group A constitute 70 women, who delivered in the period 1.1.1998-30.9.2002 into the water (fetus was expelled under water). Control group B formed 70 women, who delivered in a conventional (horizontal position) and in the same time they did not have any contraindication to waterbirth. At first we compared the length of I. and II. stage of labour, the number of episiotomies, the number of some other kinds of injuries, the postpartal uterine hypotony and the volume of blood loss. In the second phase we evaluated clinical condition of the newborn. RESULTS: Waterbirth have chosen 1.95% of the women in our department during this period. There is no statistically significant difference in the duration of I. stage of labour in both groups. The II. stage was prolonged to 9 against 6 minutes in group A, most probably because of hydroanalgetic effect of warm water, due to some inhibition of contractions and "no interference access" to labour. There is no statistical difference in complications during and after the labour in both groups. By group A we found statistically significant higher number of spontaneous, I. grade perineal ruptures, then in group B and we found reciprocal situation in number of episiotomies in both groups. There were no somatic differences by the newborns in both groups after delivery and we did not find higher occurrence of postnatal pathology by the waterbith babies either. CONCLUSION: Waterbirth is type of alternative obstetrics, which the women in birth demand, but which the obstetricians and neonatologists are afraid of, and which they consider to be possibly hazardous in the same time. There is documented evidence of much less performed episiotomies (nearly of 60%) and higher percentage deliveries without any injury (about of 9%). We did not prove any life or health threatening complication by the women in birth or by their newborns. Newborns from group A have completely comparable peri- and postnatal examination and investigation results with group B. In our study group we did not find higher occurrence of bleeding hypotonic uterus, infections or hypotension by the mother, comparing with the control group. There is often mentioned temporary bluish colour of the newborns by the critics of waterbith. This appearance we cannot comprehend as a cyanotic demonstration of fetal hypoxia but much more as the consequence of slower transformation from fetal to neonatal blood circulation. The same effect we can observe by the newborns, who were delivered conventionally in horizontal position and who are afterwards longer time connected by umbilical cord. Clear evidence for this contention is completely physiological evaluation and postnatal examination of all newborns by neonatologist after delivery and objective results of ABR and lactate from umbilical artery, which exclude fetal hypoxia too. As the conclusion we can claim, that waterbirth nowadays is one of legitimate methods of alternative obstetrics. The results of our study did confirm that this way of delivery doesnot represent any risk for the mother or the newborn and that there is no reason for an anxiety of obstetrician and neonatologist.
[Giving birth in the water: experience after 1,825 water deliveries. Retrospective descriptive comparison of water birth and traditional delivery methods] [Article in German]
Thöni A, Zech N, Ploner F., Abteilung fur Gynäkologie und Geburtshilfe, Landeskrankenhaus Sterzing, Sterzing, Italien. gynaekologie.sterzing@sb-brixen.it
Abstract
OBJECTIVE: We reviewed 1,825 water births at a single institution over a 9-year period. METHODS: We compared 830 primipara deliveries in water with 424 primipara deliveries in the traditional bed and 136 on the delivery stool. We also evaluated the duration of labour, arterial cord blood pH and base excess in the primiparae, and perineal trauma, shoulder dystocia and deliveries after preceding caesarean section as well as rates of neonatal infection in all the 1,825 water births. RESULTS: The duration of the first stage of labour was significantly shorter with water births than with the other delivery positions. The episiotomy rate for all water births was found to be much lower compared to deliveries carried out in the bed or on the birthing stool. The rate of perineal tears was similar. There were no differences in the duration of the second stage, arterial cord blood pH and base excess. No woman using the water birth method required analgesics. There were 3 shoulder dystocias with water births. Sixty-eight women delivered in water after a preceding caesarean section. CONCLUSION: Water births appears to be associated with a significantly shorter first stage of labour, a lower episiotomy rate and reduced analgesic requirements when compared with other delivery positions. If women are selected appropriately, water birth appears to be safe for both the mother and neonate.
Archives of Gynecology and Obstetrics (July 2004), 270 (1), pg. 6-9
Water birth: microbiological colonisation of the newborn, neonatal and maternal infection rate in comparison to conventional bed deliveries
P. Fehervary, E. Lauinger-Lorsch, H. Hof, F. Melchert, E.Bauer, W. Zieger;Mannheim, Germany
Abstract:
Introduction. 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. Materials and methods. 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. Results. Neonatal outcome, infantś and maternal infection rate did not differ between the three groups.
GEBURTSHILFE UND FRAUENHEILKUNDE,vol.61,no.10,pp.771-777,2001 Alternative delivery methods and changes in obstetric practice
Abstract: Objective: In 1991 we instituted a new obstetric concept at our hospital to integrate water birth, alternative delivery positions and less invasive conduct of labor into practice according to the wishes of the mother. The present study analyzed which delivery methods were chosen and how the rate of obstetric interventions has changed. Methods: We, compared our recent data (12,041 deliveries between 1991 and 1999) with data from our institution before introduction of the new concept (5602 deliveries between 1986 and 1991) and with data from a national database (328,276 deliveries in Switzerland between 1986 to 1999). We compared birth positions and rates of cesarean section, episiotomy, amniotomy, induction or augmentation of labor, and epidural anesthesia. Results: After 1991 the proportion of women delivered in bed declined to about 40% The rate of water births increased steadily to 49% of all spontaneous deliveries. The episiotomy rate decreased from over 80% to under 10%. The cesarean section rate remained lower than that in the national database. Changes in other obstetric interventions were less pronounced. Conclusion: Alternative delivery methods, particularly water birth, have become popular. This shift has helped keep the cesarean delivery rate low and decrease the episiotomy rate and has prompted more careful use of other obstetric interventions.
Iran
Arch Iran Med. 2009 Sep;12(5):468-71. Experience of water birth delivery in Iran.Chaichian S, Akhlaghi A, Rousta F, Safavi M.; Department of Obstetrics and Gynecology, Islamic Azad University, Tehran Medical Unit, Tehran, Iran. drchaichian@yahoo.comAbstractBACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSION: 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.
The criteria, which a modern obstetric department is based on, are to deliver serenely and naturally according to the mother's personal exigencies and preserving the child's right to his/her own safety. The attempt to offer the woman a natural place with respect for these principles has improved the knowledge about the physiologic changes of the female organism during labour and water birth. Our experience about water birth began on 1st of July 2000, the day of the inauguration of the new birth room of the maternal-infantile department of the hospital of Lavagna. We nursed 15 women during labour and water birth, 11 were multiparas, 4 were primiparas, the average age was 31-year-old. We used the existing criteria of maternal and fetal selection for the care of physiologic water birth with a low risk. Particularly, the fetal heart rate was monitored at least for 30 minutes before the immersion into water and then at scheduled intervals during labour. To this purpose we used a cardiotocograph provided with an ultrasound probe (with high density of crystals) and with a toco (with high sensitivity), both waterproof and wireless. In our sample the episiotomy was not performed and 3rd degree lacerations did not happen. The neonatal average weight was 3100 gr for the primiparas and 3040 gr for the multiparas, respectively. The Apgar measurement was never lower than 8. The average time of labour was 6 hours for the group of the primiparas and 4.25 hours for the multiparas, respectively. In conclusion the monitoring of fetal welfare during water labour does not substantially differ from the monitoring of traditional labour, but it requires specific equipments.
GEBURTSHILFE UND FRAUENHEILKUNDE,vol.62,no.10,pp.977-981,2002 Water birth - A review of 969 deliveries and a comparison with other delivery positions A. Thoni; K. Mussner; Sterzing, Italy Abstract Purpose: The object of our study was to analyze 969 consecutive water births and compare them with other delivery positions. Methods: We compared 969 water births, 515 deliveries in the traditional bed, and 172 deliveries on the delivery stool. Duration of labor, rates of episiotomies and lacerations, arterial cord blood pH, analgesic requirements and postpartum maternal hemoglobin levels were analyzed. Results: The first stage of labor was significantly shorter in primiparas with water birth compared with the other delivery positions (381 vs. 473 min). There were no differences in the duration of the second stage. The low episiotomy rate with the water births (0,52% compared with 17,2% and 7,6% for the other two positions) was not associated with an increased rate of perineal lacerations (23% in all three groups). Of the primiparas, 58% had no lacerations with water birth compared with 36% and 48% for the other positions, respectively. No woman with water birth required analgesics. There were no differences among the groups in arterial cord blood pH, in base-excess or postpartal maternal hemoglobin level. Conclusions: Our results suggest that water birth is associated with a significantly shorter first stage of labor, a lower episiotomy rate, fewer perineal lacerations, and reduced analgesic requirements compared with other delivery positions. Water birth appears to be safe for the mother and the fetus-neonate if candidates are selected appropriately.
Department of Gynaecology and Obstetrics, Vipiteno/Sterzing, Italy. gynaekologie.sterzing@as-bressanone.it
Abstract
OBJECTIVES: We reviewed 1600 water births at a single institution over an 8-year period. METHODS: We compared 737 primiparae deliveries in water with 407 primiparae deliveries in bed, and 142 primiparae on the delivery stool. We also evaluated the duration of labor, perineal trauma, arterial cord blood pH, postpartum maternal hemoglobin levels, and rates of neonatal infection. In 250 water deliveries we performed bacterial cultures of water samples obtained from the bath after filling and after delivery. RESULTS: The duration of the first stage of labor was significantly shorter with a water birth than with a land delivery (380 vs. 468 minutes, P<0.01). The episiotomy rate in all water births was lower with a water birth than with a delivery in bed or a delivery on the birthing stool (0.38%, 23%, and 8.4%, respectively). The rate of perineal tears was similar (23%, respectively). There were no differences in the duration of the second stage (34 vs. 37 minutes), arterial cord blood pH, or postpartum maternal hemoglobin levels. No woman using the water birth method required analgesics. The rate of neonatal infection was also not increased with a water birth (1.22% vs. 2.64%, respectively). CONCLUSION: Water birth appears to be associated with a significantly shorter first stage of labor, lower episiotomy rate and reduced analgesic requirements when compared with other delivery positions. If women are selected appropriately and hygiene rules are respected, water birth appears to be safe for both the mother and neonate.
Lachman E, Finelt Z., Dept. of Obstetrics and Gynecology, Yoseftal Hospital, Eilat.
Abstract
Underwater birth is now deemed an acceptable type of delivery. Safety is a recurring consideration, the main concern being that of drowning. But in reports of 19,000 underwater births no untoward events were noted. Also, need for pain relief and of intervention during labor were both reduced. The short term indicators of neonatal outcome were good. A recent review explains 5 different physiological factors which inhibit initiation of fetal breathing under warm water. Many studies have shown no increase in risk of infection of either mother or baby. We report our experience with 26 women, 23 of whom actually delivered in the pool with excellent results. We believe that birth under water is safe and beneficial if done properly for low-risk patients.
OBJECTIVE: The aim of this study was to assess the knowledge of alternative delivery techniques among pregnant women and their preferences concerning the course of labour. MATERIAL AND METHODS: 275 woman hospitalizated in obstetric wards in Puck and Ist Clinic in Warsaw were questionnaired in the period of July 2003 - February 2004. The mean age of women was 26 +/- 4.9. 55.7% of them were nulliparous, 44.3% multiparous. T-Student test was used for statistical analysis. RESULTS: The majority of questionnaired women knew alternative positions during delivery and possible analgetic techniques. 25.1% of women attended labour school. 81.2% wanted to give birth in the hospital, 10% at home and 8.8% in the delivery room. 51.1% preferred waterbirth and 22.5% obstetric chair--most of them came from the big cities, were better educated and attended labour school. Almost half of all women are in favour of epidural anaesthesia of delivery. Caesarean section on request was supported by 13.8%. For 67.4% the presence of intimates during labour was important. CONCLUSIONS: Labour school has a significant influence on women's knowledge and their preferences. Waterbirth and other modern delivery techniques are very popular among better educated women from big cities, while those with lower education from small cities and villages prefer "classic" labour. Therefore promotion of modern delivery methods and active participation in labour should be concentrated on these groups of women. Nowadays obstetric departments should ensure not only safety of giving birth but also complete personal comfort for pregnant women.
[Clinical condition of newborns from water birth at the Perinatology Clinic, Institute Of Gynecology and Obstetrics of the Medical University in Łódź, in the years 1996-2001] [Article in Polish]
OBJECTIVE: The objective of the paper was the estimation of the babies from the water births. DESIGN: The comparison of newborns from water births to neonates from conventional deliveries. MATERIALS AND METHODS: Mature babies, who were born in the Clinics of Perinatology in the Institute of Gynecology and Obstetrics of the Medical University in Łódź, in the years 1996-2001. Neonates whose mothers were living in Łódź district were taken into consideration and datas were gained from the medical documentation. RESULTS: Women who delivered in water were mainly intellectual and primiparas. Among the newborns from water births many of them got from 8 to 10 points by Apgar score (92.9%), and only 7.1% were estimated for 6 to 7 points. Birth weight in babies from water deliveries varied from 2300 grams to 4050 grams and the majority (59.5%) was composed of newborns weighting 3500 grams or more. Birth weight from 2500 grams to 3499 grams referred to 33.3% of the babies. In the control group from conventional deliveries, estimation by Apgar score was similar, but the body mass equal or higher than 3500 grams was seen only in 19.7% and the majority--80.3% was composed of babies with lower birth weight (2500 g-3499 g). The clinical condition of all the newborns delivered in water was good; they were healthy and only one baby suffered from inborn pneumonia, and another one from diaper dermatitis. There were no perinatal traumas in analysed babies. CONCLUSION: Taking into consideration such parameters as high Apgar score estimation, good clinical condition and absence of traumas, water delivery is to be judged as the advantageous one for newborns.
II Kliniki Ginekologii Instytutu Ginekologii i Połoznictwa Akademii Medycznej, 94-029 Łódź, ul. Wileńska 37.
Abstract
The study presents a literature review on the benefits and risk of the routine episiotomy during the second stage of labour. Perineal trauma complications as well as perinatal outcomes are discussed. The risk of stress incontinence and sexual dysfunction are described. New techniques for improve of perinatal outcomes and prevention of post partum incontinence are described. Routine episiotomy gives poor effects in many cases. Perineal massage during pregnancy, waterbirth, are most interesting methods to avoid routine episiotomy and improve the quality of life in post partum women.
OBJECTIVE: The aim of this study was to examine the influence of water immersion on the course of labor. MATERIAL AND METHODS: The study group consisted of 109 women, who have delivered in water in Obstetrical Ward in Puck from 1998 to 2000. 110 women composed control group. Mean patients' age in study and control group was respectively 26.40 +/- 4.33 and 26.72 +/- 5.82 years (ns). Gestational age was 40.69 +/- 5.91 and 39.71 +/- 2.03 weeks (ns). The duration of labor stages, time from membranes rupture to delivery, birthweight and newborns condition, frequency of episiotomy and perineum injuries as well as necessity of labor stimulants use were analyzed. Particular parameters were also assessed regarding to parity. The differences were determined using T-test. RESULTS: Mean duration of 1st labor stage was 319 min in study group and 375 min in control group (p < 0.02). The 2nd and 3rd labor stages did not differ significantly. II labor stage in nulliparous and I stage in multiparous were shorter in study group (respectively 34.41 vs. 45.5 min; p < 0.02 and 258.23 vs. 329.83 min; p < 0.02). The episiotomy was less frequent in study group (p < 0.01), whereas perineum injuries in control one (p < 0.05). Use of oxytocin was comparable between both groups. 97% of newborns from study group and 93% from control group, they were in good condition (ns). CONCLUSIONS: The profitable influence of water immersion to short 1st labor stage was noted. There were no differences in newborns' condition. The water birth is a safe method of labor in patients with physiological pregnancy.
DESIGN: The authors showed the results of the study of the influence of warm tub bath during delivery on 135 women. MATERIALS AND METHODS: In a prospective study 135 women bathed in a warm tub bath during first and second stage of labor after a strictly normal pregnancy, ending with spontaneous delivery at term. A control group consisted of 135 women fulfilling the same criteria, but who did not take the bath during labor. The newborns weight, their condition, perineum injury, time of first and second stage of delivery and number of periteotomies was analyzed. CONCLUSIONS: The observed features were undistinguishing.
OBJECTIVES: 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. STUDY DESIGN: 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. RESULTS: 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. CONCLUSIONS: 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.
The Women's University Hospital, University Hospital Basel, Basel, Switzerland. rzanetti@uhbs.ch
Abstract
OBJECTIVE: To prospectively assess the effect of water birth on maternal and fetal outcomes in a selected low-risk collective of a tertiary obstetrical unit. METHOD: 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. RESULT: 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. CONCLUSION: 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.
OBJECTIVE: 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. METHOD: 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. RESULT: 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. CONCLUSION: Regarding GBS colonization of the newborn during water birth there might be a wash out effect, which protects the children during the delivery.
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.
GEBURTSHILFE UND FRAUENHEILKUNDE,vol.65,no.5,pp.482-487,2005 Pain intensity and need for analgesics with water births and land births
Abstract Purpose: A warm bath promotes relaxation, pain relief and a sense of well-being [1]. The recommendation for a water birth is thus often coupled with the indication that it is more pleasant and less painful than a bed birth. This work investigates whether the intensity of labor pain experienced and the need for analgesics differs between water and bed births. Material and Methods: In a prospective study carried out at the Women's Clinic in Frauenfeld/Switzerland, we followed 12103 spontaneous singleton births in cephalic presentation. Of these, 4768 were water births, 5141 bed births, 1429 Maya stool births and 765 used other birthing methods. The labor pain experienced and the need for medical or paramedical analgesics were recorded and compared among the different birthing groups. Results: During the different birthing stages, all birthing methods showed an almost identical intensity of pain, as measured with the visual analogue scale (VAS 0-100): early dilation phase (VAS 38-54), late dilation and expulsion phase (VAS 70-77). When looking back during the puerperal period, first-time mothers who chose a water birth remembered the birthing experience as being significantly less painful than did their bed birthing sisters (water birth VAS 68.98, bed birth VAS 72.43). The need for analgesics was significantly lower among water birthers. Conclusion: Contrary to expectations, water births are not less painful than bed births. They do, however, improve the acceptance of labor pain, thereby reducing the analgesics required. Retrospectively, water birthers remembered the birthing experience as being less painful than bed birthers.
JOURNAL OF PERINATAL MEDICINE,vol.32,no.4,pp.308-314,2004
Waterbirths compared with landbirths: an observational study of nine years
V. Geissbuehler*, S.Stein, J. Eberhard; Department of Obstetrics and Gynecology, Cantonal Hospital, Frauenfeld, Switzerland
Abstract
Aims: This study compares neonatal and maternal morbidity and mortality between waterbirths and landbirths. (spontaneous singleton births in cephalic presentation, vacuum extractions are excluded). Methods: In this observational study covering nine years, standardized questionnaires were used to document 9,518 spontaneous singleton cephalic presentation births, of which 3,617 were waterbirths and 5,901 landbirths. Results: Landbirths show higher rates of episiotomies as well as third and fourth degree perineal lacerations. Waterbirths show a higher rate of births ‘‘without injuries’’, first and second-degree perineal lacerations, vaginal and labial tears. After a waterbirth, there is an average loss of 5.26 g/l blood; this is significantly less than landbirths where there is an 8.08 g/l blood loss on average. In 69.7% waterbirths required no analgesic, compared to 58.0% for landbirths. Water and landbirths do not differ with respect to maternal and neonatal infections. After landbirths, there was a higher rate of newborn complications with subsequent transfer to an external NICU. During the study, there were neither maternal nor neonatal deaths related to spontaneous labor. Conclusions: Waterbirths are associated with low risks for both mother and child when obstetrical guidelines are followed.
This prospective, longitudinal study spanning more than 9 years examines the influence of the birthing method, in particular water birth, on neonatal and maternal morbidity and mortality. Using questionnaires, maternal and neonatal data of 9,518 spontaneous singleton births with cephalic presentation, including 3,617 water births and 5,901 land births, were compared. Land births show significantly higher rates of episiotomies as well as third- and fourth-degree perineal tears. Waters births show a significantly higher rate of births 'without injuries', first- and second-degree perineal tears, vaginal and labial tears. The average loss of blood after water birth is -5.26 g/l; this is statistically significantly less than after land births at -8.08 g/l. In 69.7%, water births required no analgesic, compared to 30.3% for land births. Water and land births do not differ with respect to maternal and neonatal infections. After land births, there was a significantly higher rate of newborn complications with subsequent transfer to an external NICU. There were neither maternal nor neonatal deaths related to the birthing event. Water births are just as safe as land births if obstetrical guidelines are followed. Risks, such as preeclampsia, signs of infection, meconium-stained amniotic fluid and pathological CTG, are found more frequently in land births and indicate that a safe and prospective birth management is being followed.
Geissbuehler V, Eberhard J, Lebrecht A., Clinic for Obstetrics and Gynecology, Cantonal Hospital, Frauenfeld, Switzerland. vgeissbuehler@bluewin.ch
Abstract
OBJECTIVES: The Frauenfeld Clinic for Obstetrics and Gynecology introduced waterbirths in 1991. This work examines whether guidelines for water temperature and bathing are actually necessary. METHODS: This 8-year prospective clinical study follows 10,775 births in a regional women's hospital (non-selected population). Neonatal and maternal body temperature and morbidity parameters were compared between land and waterbirths. A smaller study (n = 47) selectively focused on body temperature differences as influenced by bathing time and water temperature in waterbirths as compared to land births. RESULTS: Neonatal and maternal birth and perinatal parameters, and body temperatures do not differ between water and land births, except at birth, when waterbearing temperatures were 36.9 degrees C vs. 36.3 degrees C on land. Neonatal rectal temperatures did not differ significantly between the two groups. Water temperature increased from the beginning of the bath (35.2 degrees C) to 35.7 degrees C, and fell at the end of the bath to 32.9 degrees C. Water temperature range: 23 degrees C to 38.9 degrees C. Bathing duration: 28 min. to 364 min. CONCLUSIONS: Waterbirths pose no thermal risk. The parturient, with her "inborn code of body temperature regulation," regulates water temperature and bathing duration to ensure body temperatures of mother and child remain within the physiological range. Cumbersome guidelines for water temperature and bathing duration are therefore superfluous.
Geissbühler V, Eberhard J., Clinic for Obstetrics and Gynecology, Thurgauisches Kantonsspital, Frauenfeld, Switzerland. vgeissbuehler@bluewin.ch
Abstract
BACKGROUND: 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. 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). RESULTS: 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. CONCLUSION: 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.
Eberhard J, Geissbühler V., Clinic for Obstetrics and Gynecology, Cantonal Hospital, Frauenfeld, Switzerland.
Abstract
BACKGROUND: Because of popular demand for more natural childbirth, a new concept was introduced in 1991 in our clinic. It consisted of careful monitoring and birth management, restrictive use of invasive methods, and free choice of different birth methods including waterbirths and other alternative birth methods. Our aim was to determine the influence of our new birth concept on the way women give birth and on the birth management in our clinic. METHODS: In a total of 9,418 births between 1991 and 1997 [new birth concept KSF (KSF = Kantonsspital Frauenfeld)], the changing pattern of birth methods and birth management in our clinic under the influence of the new birth concept were analysed. The results were compared to a historical group in our clinic, a total of 5,602 births from 1986 to 1990, and to data from a contemporary group from Swiss clinics, a total of 344,328 births from 1986 to 1997. FINDINGS: Our study shows that alternative birth methods are very popular. The waterbirth rates have risen steadily and stabilized at around 40-50% of the spontaneous births. The Maia-birthing stool births rates reached a peak of popularity in 1993 (23%) 5 years after their introduction, dropping again to 10% of the spontaneous births. The bedbirth rates have stabilized at around 40% of the spontaneous births. Other birth methods such as standing, supported by a rope, on the mat or on all fours are much less popular. The impact of our new birth concept on different aspects of birth management differs greatly from one to another. The episiotomy rate has dropped from a previous rate higher than 80% to a rate lower than 15%. The caesarean section rate in our clinic (around 10%) has remained substantially below the Swiss average (around 15%). The rate of the spinal and epidural analgesia was maintained at a constant level, around 13%, while the Swiss average rates doubled and reached 23% in 1997. The induction and amniotomy rates as well as the use of oxytocin were not influenced by the new birth concept and are comparable to the Swiss average. CONCLUSION: Alternative birth methods and in particular waterbirths are very sought after. This popular pressure insisting upon less invasive, more natural birth management can be well integrated into the security-oriented way of thinking of classical medicine. In our clinic the general trend towards more invasive measures in birth management could be countered by the introduction of a new birth concept with alternative birth methods.
Wu CJ, Chung UL., National Taipei College of Nursing, No. 365 Ming-Te Road, Pei-Tou, Taipei 112, Taiwan, ROC. uelin@mail1.ntch.edu.tw
Abstract
Waterbirth has been a way of birth for 20 to 30 years abroad, while in Taiwan, only in the past three years have some women chosen water birth. This study aims to explore the decision-making experience of mothers selecting waterbirth. A phenomenological approach was employed in this study. Nine mothers who had given birth in water successfully in the midwife clinic in the past year were chosen and one-by-one, face-to-face interviews were conducted. The research tools included a basic information questionnaire, a semi-structured and open-ended interview guide, and an audio recorder to record the entire interviews. The content of the interviews was faithfully transcribed and analyzed with Giorgi's phenomenological method and Lincoln and Guba's qualitative credibility. Four main concepts concluded from the experience context of the studied women were: (1) Dissatisfaction with existing obstetric practices; (2) Demonstration of autonomy; (3) Consideration of relatives' attitude; and (4) Employing strategies to achieve goals. The result of this study can help nursing staff and the public to understand the decision-making experience of mothers selecting waterbirth, and help the contemplation of health care providers with respect to furnishing a more humanized birth environment in hospitals.
United Kingdom
BJOG: an International Journal of Obstetrics and Gynaecology June 2004, Vol. 111, pp. 537–545
A pilot study for a randomised controlled trial of waterbirth versus land birth
J. Woodward, S.M. Kellyb; UK
Abstract
Objectives To assess the feasibility of undertaking an adequately powered multicentre study comparing waterbirth with land birth. To assess whether women are willing to participate in such a trial and whether participation has a negative effect on their birthing experience. Design A randomised controlled trial (RCT) with ‘preference arm’. Setting District general hospital with 3600 deliveries annually. Population Women with no pregnancy complications and no anticipated problems for labour/delivery. Methods Women were recruited and randomised between 36 and 40 weeks of gestation. Comparison of randomised and ‘preference arm’ to assess any impact of randomisation on women’s birthing experience. Main outcome measures Data were collected at delivery concerning the labour, the pool water and baby’s condition at birth and six weeks of age. The main outcome measures are means and standard deviation of cord O2, CO2, haemoglobin, haematocrit and base excess; medians and ranges of time to first breathe and cord pH; bacterial growth from pool water samples and neonatal swabs; and maternal satisfaction. Results Eighty women participated—60 women were randomised. Twenty women participated in a nonrandomized ‘preference arm’. The babies randomised to a waterbirth demonstrated a significantly lower umbilical artery pCO2 (P ¼ 0.003); however, it is recognised that this study is underpowered. Women were willing to participate and randomisation did not appear to alter satisfaction. Conclusion This small study has shown that a RCT is feasible and demonstrated outcome measures, which can be successfully collected in an average delivery suite.
Cochrane Database Syst Rev. 2004;(2):CD000111. Immersion in water in pregnancy, labour and birth.Cluett ER, Nikodem VC, McCandlish RE, Burns EE., School of Nursing and Midwifery, University of Southampton, Nightingale Building (67), Highfield, Southampton, Hants, UK, SO17 1BJ.AbstractBACKGROUND: Enthusiasts for immersion in water during labour, and birth have advocated its use to increase maternal relaxation, reduce analgesia requirements and promote a midwifery model of supportive care. Sceptics are concerned that there may be greater harm to women and/or babies, for example, a perceived risk associated with neonatal inhalation of water and maternal/neonatal infection. OBJECTIVES: To assess the evidence from randomised controlled trials about the effects of immersion in water during pregnancy, labour, or birth on maternal, fetal, neonatal and caregiver outcomes. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group trials register (September 2003). SELECTION CRITERIA: All randomised controlled trials comparing any kind of bath tub/pool with no immersion during pregnancy, labour or birth. DATA COLLECTION AND ANALYSIS: We assessed trial eligibility and quality and extracted data independently. One reviewer entered the data and another checked them for accuracy. MAIN RESULTS: : Eight trials are included (2939 women). No trials were identified that evaluated immersion versus no immersion during pregnancy, considered different types of baths/pools, or considered the management of third stage of labour. There was a statistically significant reduction in the use of epidural/spinal/paracervical analgesia/anaesthesia amongst women allocated to water immersion water during the first stage of labour compared to those not allocated to water immersion (odds ratio (OR) 0.84, 95% confidence interval (CI) 0.71 to 0.99, four trials). There was no significant difference in vaginal operative deliveries (OR 0.83, 95% CI 0.66 to 1.05, six trials), or caesarean sections (OR 1.33, 95% CI 0.92 to 1.91). Women who used water immersion during the first stage of labour reported statistically significantly less pain than those not labouring in water (40/59 versus 55/61) (OR 0.23, 95% CI 0.08 to 0.63, one trial). There were no significant differences in incidence of an Apgar score less than 7 at five minutes (OR 1.59, 95% CI 0.63 to 4.01), neonatal unit admissions (OR 1.05, 95% CI 0.68 to 1.61), or neonatal infection rates (OR 2.01, 95% CI 0.50 to 8.07). REVIEWERS' CONCLUSIONS: There is evidence that water immersion during the first stage of labour reduces the use of analgesia and reported maternal pain, without adverse outcomes on labour duration, operative delivery or neonatal outcomes. The effects of immersion in water during pregnancy or in the third stage are unclear. One trial explores birth in water, but is too small to determine the outcomes for women or neonates.
Richmond H., Anglia Polytechnic University, Queen Elizabeth Hospital, London.
Abstract
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.
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.
Gilbert RE, Tookey PA., Department of Epidemiology and Public Health, Institute of Child Health, London WC1N 1EH. r.gilbert@ich.ucl.ac.uk
Abstract
AIM: To compare perinatal morbidity and mortality for babies delivered in water with rates for babies delivered conventionally (not in water). DESIGN: Surveillance study (of all consultant paediatricians) and postal survey (of all NHS maternity units). SETTING: British Isles (surveillance study); England and Wales (postal survey). SUBJECTS: Babies born in the British Isles between April 1994 and March 1996 who died perinatally or were admitted for special care within 48 hours of birth after delivery in water or after labour in water followed by conventional delivery (surveillance study); babies delivered in water in England and Wales in the same period (postal survey). MAIN OUTCOME MEASURESE Number of deliveries in water in the British Isles that resulted in perinatal death or in admission to special care within 48 hours of birth; and proportions (of such deliveries) of all water births in England and Wales. RESULTS: 4032 deliveries (0.6% of all deliveries) in England and Wales occurred in water. Perinatal mortality was 1.2/1000 (95% confidence interval 0.4 to 2.9) live births; 8.4/1000 (5.8 to 11.8) live births were admitted for special care. No deaths were directly attributable to delivery in water, but 2 admissions were for water aspiration. UK reports of mortality and special care admission rates for babies of women considered to be at low risk of complications during delivery who delivered conventionally ranged from 0.8/1000 (0. 2 to 4.2) to 4.6/1000 (0.1 to 25) live births and from 9.2 (1.1 to 33) to 64/1000 (58 to 70) live births respectively. Compared with regional data for low risk, spontaneous, normal vaginal deliveries at term, the relative risk for perinatal mortality associated with delivery in water was 0.9 (99% confidence interval 0.2 to 3.6). CONCLUSIONS: Perinatal mortality is not substantially higher among babies delivered in water than among those born to low risk women who delivered conventionally. The data are compatible with a small increase or decrease in perinatal mortality for babies delivered in water.
Midwifery (March 1998), 14 (1), pg. 30-36
Staying in control: Women's experiences of labour in water
S. M. Hall. I.M. Holloway, Dorset, UK
Abstract:
Aim: to examine women's attempts at control during labour in water. Design: an exploratory design consisting of tape-recorded, in-depth interviews using the grounded theory approach. Setting: a medium sized town in the south of England. The data were collected in the maternity unit of a local general hospital set in a semi-rural location. Participants: nine women who had chosen to spend their labour process in water. The participants selected had experienced a normal pregnancy and given birth to a healthy baby at term. Findings: labour in water was seen by all but one of the participants as beneficial, particularly as they felt that this gave them more control over the process. They valued their own involvement in determining the outcome of their care. The support of the midwife in making decisions was seen as necessary to remain in control. Conclusions: labour in water was a positive experience for this group of healthy women. The feeling of freedom to make decisions, however, was balanced with a wish for the support of the midwife.
School of Nursing and Midwifery, University of Southampton, Highfield, UK.
Abstract
OBJECTIVE: to evaluate the feasibility of a randomised controlled trial (RCT) examining the effect of three options (augmentation, conservative and water) for the management of dystocia in nulliparae. The main objectives were to explore the feasibility of trial procedures in the clinical environment, consent rates and acceptability of the management options to women, local incidence of dystocia in nulliparae and the size of the subsequent study. DESIGN: a two part study: a pilot, RCT with follow-up through to delivery with postnatal maternal surveys, and a case review of nulliparae with dystocia. SETTING: a large maternity unit in the South of England in May-July 1997 inclusive. PARTICIPANTS: nulliparae with dystocia in the first stage of labour who had an otherwise uncomplicated obstetric background. INTERVENTIONS: women in the pilot RCT received one of three management options: labouring in a waterbirth pool, conservative management or augmentation of labour, which is the standard management of women with dystocia condition in the Unit. FINDINGS: it is feasible to conduct an RCT of management of dystocia in the Unit. Seventy per cent (95% confidence interval 47% to 87%) of women approached agreed to participate. Conservative management was the least acceptable option to women and has been dropped from the subsequent trial. The audit provided some idea of possible differences in operative delivery and epidural rates depending on augmentation or not. A sample of 220 women should be large enough to detect moderate changes and will require a 2-year recruitment period. CONCLUSIONS: a subsequent trial is feasible and is now underway. It has the potential to provide information enabling women and practitioners to have a greater choice of care options in the presence of dystocia, or provide a good basis for an even larger trial.
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