Immersion in water during labour and birth.

BACKGROUND: Water immersion during labour and birth is increasingly popular and is becoming widely accepted across many countries, and particularly in midwifery-led care settings. However, there are concerns around neonatal water inhalation, increased requirement for admission to neonatal intensive care unit (NICU), maternal and/or neonatal infection, and obstetric anal sphincter injuries (OASIS). This is an update of a review last published in 2011. OBJECTIVES: To assess the effects of water immersion during labour and/or birth (first, second and third stage of labour) on women and their infants. SEARCH METHODS: We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) (18 July 2017), and reference lists of retrieved trials. SELECTION CRITERIA: We included randomised controlled trials (RCTs) comparing water immersion with no immersion, or other non-pharmacological forms of pain management during labour and/or birth in healthy low-risk women at term gestation with a singleton fetus. Quasi-RCTs and cluster-RCTs were eligible for inclusion but none were identified. Cross-over trials were not eligible for inclusion. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. Two review authors assessed the quality of the evidence using the GRADE approach. MAIN RESULTS: This review includes 15 trials conducted between 1990 and 2015 (3663 women): eight involved water immersion during the first stage of labour; two during the second stage only; four during the first and second stages of labour, and one comparing early versus late immersion during the first stage of labour. No trials evaluated different baths/pools, or third-stage labour management. All trials were undertaken in a hospital labour ward setting, with a varying degree of medical intervention considered as routine practice. No study was carried out in a midwifery-led care setting. Most trial authors did not specify the parity of women. Trials were subject to varying degrees of bias: the intervention could not be blinded and there was a lack of information about randomisation, and whether analyses were undertaken by intention-to-treat.Immersion in water versus no immersion (first stage of labour)There is probably little or no difference in spontaneous vaginal birth between immersion and no immersion (82% versus 83%; risk ratio (RR) 1.01, 95% confidence interval (CI) 0.97 to 1.04; 6 trials; 2559 women; moderate-quality evidence); instrumental vaginal birth (14% versus 12%; RR 0.86, 95% CI 0.70 to 1.05; 6 trials; 2559 women; low-quality evidence); and caesarean section (4% versus 5%; RR 1.27, 95% CI 0.91 to 1.79; 7 trials; 2652 women; low-quality evidence). There is insufficient evidence to determine the effect of immersion on estimated blood loss (mean difference (MD) -14.33 mL, 95% CI -63.03 to 34.37; 2 trials; 153 women; very low-quality evidence) and third- or fourth-degree tears (3% versus 3%; RR 1.36, 95% CI 0.85 to 2.18; 4 trials; 2341 women; moderate-quality evidence). There was a small reduction in the risk of using regional analgesia for women allocated to water immersion from 43% to 39% (RR 0.91, 95% CI 0.83 to 0.99; 5 trials; 2439 women; moderate-quality evidence). Perinatal deaths were not reported, and there is insufficient evidence to determine the impact on neonatal intensive care unit (NICU) admissions (6% versus 8%; average RR 1.30, 95% CI 0.42 to 3.97; 2 trials; 1511 infants; I² = 36%; low-quality evidence), or on neonatal infection rates (1% versus 1%; RR 2.00, 95% CI 0.50 to 7.94; 5 trials; 1295 infants; very low-quality evidence).Immersion in water versus no immersion (second stage of labour)There were no clear differences between groups for spontaneous vaginal birth (97% versus 99%; RR 1.02, 95% CI 0.96 to 1.08; 120 women; 1 trial; low-quality evidence); instrumental vaginal birth (2% versus 2%; RR 1.00, 95% CI 0.06 to 15.62; 1 trial; 120 women; very low-quality evidence); caesarean section (2% versus 1%; RR 0.33, 95% CI 0.01 to 8.02; 1 trial; 120 women; very low-quality evidence), and NICU admissions (11% versus 9%; RR 0.78, 95% CI 0.38 to 1.59; 2 trials; 291 women; very low-quality evidence). Use of regional analgesia was not relevant to the second stage of labour. Third- or fourth-degree tears, and estimated blood loss were not reported in either trial. No trial reported neonatal infection but did report neonatal temperature less than 36.2°C at birth (9% versus 9%; RR 0.98, 95% CI 0.30 to 3.20; 1 trial; 109 infants; very low-quality evidence), greater than 37.5°C at birth (6% versus 15%; RR 2.62, 95% CI 0.73 to 9.35; 1 trial; 109 infants; very low-quality evidence), and fever reported in first week (5% versus 2%; RR 0.53, 95% CI 0.10 to 2.82; 1 trial; 171 infants; very low-quality evidence), with no clear effect between groups being observed. One perinatal death occurred in the immersion group in one trial (RR 3.00, 95% CI 0.12 to 72.20; 1 trial; 120 infants; very low-quality evidence). The infant was born to a mother with HIV and the cause of death was deemed to be intrauterine infection.There is no evidence of increased adverse effects to the baby or woman from either the first or second stage of labour.Only one trial (200 women) compared early and late entry into the water and there were insufficient data to show any clear differences. AUTHORS' CONCLUSIONS: In healthy women at low risk of complications there is moderate to low-quality evidence that water immersion during the first stage of labour probably has little effect on mode of birth or perineal trauma, but may reduce the use of regional analgesia. The evidence for immersion during the second stage of labour is limited and does not show clear differences on maternal or neonatal outcomes intensive care. There is no evidence of increased adverse effects to the fetus/neonate or woman from labouring or giving birth in water. Available evidence is limited by clinical variability and heterogeneity across trials, and no trial has been conducted in a midwifery-led setting.

Evaluating a Midwife-Led Model of Antenatal Care for Women with a Previous Cesarean Section: A Retrospective, Comparative Cohort Study.

BACKGROUND: Research is yet to identify effective and safe interventions to increase the vaginal birth after cesarean (VBAC) rate. This research aimed to compare intended and actual VBAC rates before and after implementation of midwife-led antenatal care for women with one previous cesarean birth and no other risk factors in a large, tertiary maternity hospital in England. METHODS: This was a retrospective, comparative cohort study. Data were collected from the medical records of women with one previous lower segment cesarean delivery and no other obstetric, medical, or psychological complications who gave birth at the hospital before (2008) and after (2011) the implementation of midwife-led antenatal care. Chi-squared analysis was used to calculate the odds ratio, and logistic regression to account for confounders. RESULTS: Intended and actual VBAC rates were higher in 2011 compared with 2008: 90 percent vs. 77 percent, adjusted odds ratio (aOR) 2.69 (1.48-4.87); and 61 percent vs. 47 percent, aOR 1.79 (1.17-2.75), respectively. Mean rates of unscheduled antenatal care sought via the delivery suite and inpatient admissions were lower in 2011 than 2008. Postnatal maternal and neonatal safety outcomes were similar between the two groups, except mean postnatal length of stay, which was shorter in 2011 compared with 2008 (2.67 vs. 3.15 days). CONCLUSIONS: Implementation of midwife-led antenatal care for women with one previous cesarean offers a safe and effective alternative to traditional obstetrician-led antenatal care, and is associated with increased rates of intended and actual VBAC.

Characteristics, interventions, and outcomes of women who used a birthing pool: a prospective observational study.

BACKGROUND: Birthing pools are integrated into maternity care in the United Kingdom and are a popular care option for women in midwifery-led units and at home. The objective of this study was to describe and compare maternal characteristics, intrapartum events, interventions, and maternal and neonatal outcomes by planned place of birth for women who used a birthing pool. METHODS: A total of 8,924 women at low risk of childbirth complications were recruited from care settings in England, Scotland, and Northern Ireland. Descriptive analysis was performed. RESULTS: Overall, 7,915 (88.9%) women had a spontaneous birth (5,192, 58.3% water births), of whom 4,953 (55.5%) were nulliparas. Fewer nulliparas whose planned place of birth was the community (freestanding midwifery unit or home) had labor augmentation by artificial membrane rupture (149, 11.3% [95% CI: 9.6-13.1]), compared with an alongside midwifery unit (271, 22.7% [95% CI: 20.3-25.2]), or obstetric unit (639, 26.3% [95% CI: 24.5-28.1]). Results were similar for epidural analgesia and episiotomy. More community nulliparas had spontaneous birth (1,172, 88.9% [95% CI: 87.1-90.6]), compared with birth in an alongside midwifery unit (942, 79% [95% CI: 76.6-81.3]) and obstetric unit (1,923, 79.2% [95% CI: 77.5-80.8]); and fewer required hospital transfer (265, 20% [95% CI: 17-22.2]) compared with those in an alongside midwifery unit (370, 31% [95% CI: 28.3-33.7]). Results for multiparas and newborns were similar across care settings. Twenty babies had an umbilical cord snap, 18 (90%) of which occurred during water birth. CONCLUSIONS: Birthing pool use was associated with a high frequency of spontaneous birth, particularly among nulliparas. Findings revealed differences in midwifery practice between obstetric units, alongside midwifery units, and the community, which may affect outcomes, particularly for nulliparas. No evidence was found for a difference across care settings in interventions or outcomes in multiparas or in outcomes for newborns. During water birth, it is important to prevent undue traction on the cord as the baby is guided to the surface.

Immersion in water in labour and birth.

BACKGROUND: Enthusiasts suggest that labouring in water and waterbirth increase maternal relaxation, reduce analgesia requirements and promote a midwifery model of care. Sceptics cite the possibility of neonatal water inhalation and maternal/neonatal infection. OBJECTIVES: To assess the evidence from randomised controlled trials about immersion in water during labour and waterbirth on maternal, fetal, neonatal and caregiver outcomes. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (October 2008). SELECTION CRITERIA: Randomised controlled trials comparing any bath tub/pool with no immersion during labour and/or birth. DATA COLLECTION AND ANALYSIS: We assessed trial eligibility and quality and extracted data independently. One review author entered data and another checked for accuracy. MAIN RESULTS: This review includes 11 trials (3146 women); eight related to the first stage of labour, one to the first and second stages, one to early versus late immersion in the first stage of labour, and another to the second stage. We identified no trials evaluating different baths/pools, or the management of third stage of labour.Results for the first stage of labour showed there was a significant reduction in the epidural/spinal/paracervical analgesia/anaesthesia rate amongst women allocated to water immersion compared to controls (478/1254 versus 529/1245; odds ratio (OR) 0.82, 95% confidence interval (CI) 0.70 to 0.98, six trials). There was no difference in assisted vaginal deliveries (OR 0.84, 95% CI 0.66 to 1.06, seven trials), caesarean sections (OR 1.23, 95% CI 0.86 to 1.75, eight trials), perineal trauma or maternal infection. There were no differences for Apgar score less than seven at five minutes (OR 1.59, 95% CI 0.63 to 4.01, five trials), neonatal unit admissions (OR 1.06, 95% CI 0.70 to 1.62, three trials), or neonatal infection rates (OR 2.01, 95% CI 0.50 to 8.07, five trials).A lack of data for some comparisons prevented robust conclusions. Further research is needed. AUTHORS' CONCLUSIONS: Evidence suggests that water immersion during the first stage of labour reduces the use of epidural/spinal analgesia. There is limited information for other outcomes related to water use during the first and second stages of labour, due to intervention and outcome variability. There is no evidence of increased adverse effects to the fetus/neonate or woman from labouring in water or waterbirth. The fact that use of water immersion in labour and birth is now a widely available care option for women threatens the feasibility of a large, multicentre randomised controlled trial.

Supervising undergraduate research: a collective approach utilising groupwork and peer support.

BACKGROUND: Nursing education now requires graduate entry for professional registration. The challenge is to ensure that students develop independence and team working in a resource effective manner. The dissertation is one opportunity for this. AIM: To evaluate changing from individual dissertation supervision to group peer supervision. METHODS: Group supervision was implemented for one cohort. Dissertation outcomes were compared with two previous cohorts. Student evaluative data was assessed. FINDINGS: Group supervision did not adversely affect dissertation outcomes (p=0.85). 88% of students reported peer supervision to be helpful, with themes being 'support and sharing', and 'progress and moving forward'. CONCLUSIONS: Peer group support provided consistent supervision harnessing the energy and resources of the students and Faculty, without adversely affecting outcomes.

A review of the father-child relationship in the development and maintenance of adolescent anorexia and bulimia nervosa.

There are disproportionately fewer studies examining the role of the father in the development of child and adolescent psychopathology. This is pertinent in the field of eating disorders, where there is a wealth of research related to family influences and the value of family-based interventions. This article reviews the key themes within the literature around the potential impact of the father-child relationship on the development and maintenance of Anorexia and Bulimia Nervosa in young people. The critical review searched relevant health and social care databases, as well as manually searching key journals in the eating disorder field. In these results, 13 studies met the inclusion/exclusion criteria and were critiqued, with 8 being taken forward for discussion. The 8 studies identified key themes within the relationship of the father and child (particularly daughters) around conflict and communication, parental protection and psychological control, emotional regulation and self-esteem, and self-perfectionism. All of these factors appear to influence the child's level of self-determining autonomy, which in turn can impact maladaptive eating attitudes and psychopathology. Tentative recommendations are made around working with fathers to encourage free expression of ideas and foster a sense of autonomy through compromise and collaboration with their adolescent child. Further research around these themes in relation to other family members is also suggested.

Immersion in water in labour and birth

BACKGROUND: Enthusiasts suggest that labouring in water and waterbirth increase maternal relaxation, reduce analgesia requirements and promote a midwifery model of care. Critics cite the risk of neonatal water inhalation and maternal/neonatal infection. OBJECTIVES: To assess the evidence from randomised controlled trials about immersion in water during labour and waterbirth on maternal, fetal, neonatal and caregiver outcomes. METHODS: Search methods: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 June 2011) and reference lists of retrieved studies. Selection criteria: Randomised controlled trials comparing immersion in any bath tub/pool with no immersion, or other non-pharmacological forms of pain management during labour and/or birth, in women during labour who were considered to be at low risk of complications, as defined by the researchers. Data collection and analysis: We assessed trial eligibility and quality and extracted data independently. One review author entered data and the other checked for accuracy. MAIN RESULTS: This review includes 12 trials (3,243 women): 8 related to just the first stage of labour: one to early versus late immersion in the first stage of labour; two to the first and second stages; and another to the second stage only. We identified no trials evaluating different baths/pools, or the management of third stage of labour. Results for the first stage of labour showed there was a significant reduction in the epidural/spinal/paracervical analgesia/anaesthesia rate amongst women allocated to water immersion compared to controls (478/1,254 versus 529/1,245; risk ratio (RR) 0.90; 95% confidence interval (CI) 0.82 to 0.99, six trials). There was also a reduction in duration of the first stage of labour (mean difference -32.4 minutes; 95% CI -58.7 to -6.13). There was no difference in assisted vaginal deliveries (RR 0.86; 95% CI 0.71 to 1.05, seven trials), ...

Randomised controlled trial of labouring in water compared with standard of augmentation for management of dystocia in first stage of labour.

OBJECTIVES: To evaluate the impact of labouring in water during first stage of labour on rates of epidural analgesia and operative delivery in nulliparous women with dystocia. DESIGN: Randomised controlled trial. SETTING: University teaching hospital in southern England. PARTICIPANTS: 99 nulliparous women with dystocia (cervical dilation rate < 1 cm/hour in active labour) at low risk of complications. Interventions Immersion in water in birth pool or standard augmentation for dystocia (amniotomy and intravenous oxytocin). MAIN OUTCOME MEASURES: Primary: epidural analgesia and operative delivery rates. Secondary: augmentation rates with amniotomy and oxytocin, length of labour, maternal and neonatal morbidity including infections, maternal pain score, and maternal satisfaction with care. RESULTS: Women randomised to immersion in water had a lower rate of epidural analgesia than women allocated to augmentation (47% v 66%, relative risk 0.71 (95% confidence interval 0.49 to 1.01), number needed to treat for benefit (NNT) 5). They showed no difference in rates of operative delivery (49% v 50%, 0.98 (0.65 to 1.47), NNT 98), but significantly fewer received augmentation (71% v 96%, 0.74 (0.59 to 0.88), NNT 4) or any form of obstetric intervention (amniotomy, oxytocin, epidural, or operative delivery) (80% v 98%, 0.81 (0.67 to 0.92), NNT 5). More neonates of women in the water group were admitted to the neonatal unit (6 v 0, P = 0.013), but there was no difference in Apgar score, infection rates, or umbilical cord pH. CONCLUSIONS: Labouring in water under midwifery care may be an option for slow progress in labour, reducing the need for obstetric intervention, and offering an alternative pain management strategy.