Maternal and neonatal outcomes among spontaneous vaginal births occurring in or out of water following intrapartum water immersion: The POOL cohort study.

OBJECTIVE: Warm water immersion during labour provides women with analgesia and comfort. This cohort study aimed to establish among women using intrapartum water immersion analgesia, without antenatal or intrapartum risk factors, whether waterbirth is as safe for them and their babies as leaving the water before birth. DESIGN: Cohort study with non-inferiority design. SETTING: Twenty-six UK NHS maternity services. SAMPLE: A total of 73 229 women without antenatal or intrapartum risk factors, using intrapartum water immersion, between 1 January 2015 and 30 June 2022. The analysis excluded 12 827 (17.5%) women who received obstetric or anaesthetic interventions before birth. METHODS: Non-inferiority analysis of retrospective and prospective data captured in NHS maternity and neonatal information systems. MAIN OUTCOME MEASURES: Maternal primary outcome: obstetric anal sphincter injury (OASI) by parity; neonatal composite primary outcome: fetal or neonatal death, neonatal unit admission with respiratory support or administration of antibiotics within 48 hours of birth. RESULTS: Rates of the primary outcomes were no higher among waterbirths compared with births out of water: rates of OASI among nulliparous women (waterbirth: 730/15 176 [4.8%] versus births out of water: 641/12 210 [5.3%]; adjusted odds ratio [aOR] 0.97, one-sided 95% CI, -∞ to 1.08); rates of OASI among parous women (waterbirth: 269/24 451 [1.1%] versus births out of water 144/8565 [1.7%]; aOR 0.64, one-sided 95% CI -∞ to 0.78) and rates of the composite adverse outcome among babies (waterbirth 263/9868 [2.7%] versus births out of water 224/5078 [4.4%]; aOR 0.65, one-sided 95% CI -∞ to 0.79). CONCLUSION: Among women using water immersion during labour, remaining in the pool and giving birth in water was not associated with an increase in the incidence of adverse primary maternal or neonatal outcomes.

Experiences of water immersion during childbirth: a qualitative thematic synthesis.

BACKGROUND: The increasing demand for childbirth care based on physiological principles has led official bodies to encourage health centers to provide evidence-based care aimed at promoting women's participation in informed decision-making and avoiding excessive medical intervention during childbirth. One of the goals is to reduce pain and find alternative measures to epidural anesthesia to enhance women's autonomy and well-being during childbirth. Currently, water immersion is used as a non-pharmacological method for pain relief. This review aimed to identify and synthesize evidence on women's and midwives' experiences, values, and preferences regarding water immersion during childbirth. METHODS: A systematic review and thematic synthesis of qualitative evidence were conducted. Databases were searched and references were checked according to specific criteria. Studies that used qualitative data collection and analysis methods to examine the opinions of women or midwives in the hospital setting were included. Non-qualitative studies, mixed-methods studies that did not separately report qualitative results, and studies in languages other than English or Spanish were excluded. The Critical Appraisal Skills Program Qualitative Research Checklist was used to assess study quality, and results were synthesized using thematic synthesis. RESULTS: Thirteen studies met the inclusion criteria and were included in this review. The qualitative studies yielded three key themes: 1) reasons identified by women and midwives for choosing a water birth, 2) benefits experienced in water births, and 3) barriers and facilitators of water immersion during childbirth. CONCLUSIONS: The evidence from qualitative studies indicates that women report benefits associated with water birth. From the perspective of midwives, ensuring safe water births requires adequate resources, midwives training, and rigorous standardized protocols to ensure that all pregnant women can safely opt for water immersion during childbirth with satisfactory results.

Insights of healthcare professionals regarding waterbirths and water immersion during labour: A mixed studies review.

AIM: To consolidate healthcare professionals' insights about waterbirths and water immersion during labour. DESIGN: Mixed studies review. DATA SOURCES: Seven electronic databases were searched from their inception dates till June 2023: PubMed, Embase, CINAHL, PsycINFO, Web of Science, Scopus, ProQuest Dissertations and Theses Global. METHODS: The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines and Pluye and Hong's mixed studies review framework guided this review. The quality of included studies was evaluated using the Mixed Methods Appraisal Tool. Findings were synthesized using the convergent qualitative synthesis method, and results were thematically analysed using Braun and Clarke's framework. RESULTS: Three main themes were identified from the 22 included studies: (1) believing in waterbirths, (2) opposing forces and (3) plotting the course ahead. CONCLUSION: Healthcare professionals reported different views about waterbirths and water immersion practices; midwives were most likely to support these practices, followed by nurses and lastly, few physicians supported them. Reasons for opposing waterbirths include insufficient training and support from colleagues as well as concerns about work efficiency, waterbirth safety and litigation issues. IMPACT: The available evidence suggests the need to provide waterbirth training for healthcare professionals, equip healthcare facilities with necessary waterbirth-related infrastructure and develop appropriate waterbirth policies/guidelines. Healthcare professionals could also consider providing antenatal waterbirth education to women and obtain women's feedback to improve current policies/guidelines. Future research should explore the views of different types of healthcare professionals from more diverse cultures. REPORTING METHOD: The PRISMA guidelines. NO PATIENT OR PUBLIC CONTRIBUTION: Systematic review.

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.

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.

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.

Waterbirths were associated with low pain relief during delivery, high breastfeeding success and healthy newborn infants.

AIM: Our aim was to compare the outcomes of waterbirths and conventional births in a Finnish hospital setting for the first time. METHODS: This retrospective study compared waterbirths with conventional low-risk deliveries from September 2018 to March 2021 at a level-two hospital in Finland. Cases and controls were collected from the patient records database. RESULTS: The study comprised 78 waterbirths and 1623 matched conventional births. Mothers in the waterbirth group only required a quarter of the amount of pain medication required by those in the control group. Babies born in water had slightly lower birth temperatures than those born conventionally (36.6 versus 36.8°C). Umbilical cord artery and vein pH were slightly higher in the waterbirth group than in the control group (artery 7.31 versus 7.28 and vein 7.38 versus 7.35). The Apgar scores did not differ. Hospital stays were shorter in the waterbirth group than in the conventional birth group (1.90 versus 2.33 days). Babies in the waterbirth group were significantly less likely to require formula than those in the conventional birth group during their hospital stay. CONCLUSION: Waterbirth decreased the requirement for maternal pain medication and favoured greater breastfeeding and earlier discharge. Prospective studies must confirm these findings.

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.

Sexuality and childbirth: a qualitative analysis of women who had a waterbirth.

Waterbirth is associated with a less painful childbirth, enhanced couples' intimacy, and positive feelings toward women's bodies and sexuality. In a qualitative, descriptive case study involving 21 participants, we examined the sexual experiences-during childbirth and postpartum-of women who had a waterbirth in a hospital environment. Women discussed their sexuality in the intrapartum and postpartum period after having a waterbirth in public or private hospitals. Two main themes were developed from the data analysis: 'women's sexual pleasure during waterbirth' and 'sexuality after childbirth'. Experiences included transcendence during waterbirth, a feeling that it represented a unique experience, and couples' more positive feelings about intimacy. The shared representations of women suggest that waterbirth can be a calming, joyful event for couples. During this process, they felt that it was a loving, shared event. In addition, after childbirth women experienced positive feelings toward their bodies and sexuality (including orgasm), as well as closer intimacy with their partners.

The effects of water immersion and epidural analgesia on cellular immune response, neuroendocrine, and oxidative markers

Background/aim: Water immersion and epidural analgesia are the most preferred pain relief methods during the labor process. Adverse effects related to these methods, impact on the labor, and perception of pain is well studied in the literature. We aimed to investigate the cord blood level of copeptin, total serum oxidant (TOS), antioxidant (TAS), interleukin (IL)-1, IL-6, and oxytocin after the labor with water immersion, epidural analgesia, and vaginal birth without pain relief. Materials and methods: The study was conducted with 102 healthy pregnant women admitted to the obstetric delivery unit for noncomplicated term birth. Copeptin, oxytocin, TAS, TOS, IL-1, and IL-6 levels of cord blood and obstetric and neonatal results after vaginal birth were compared. Results: The study included a total of 102 patients (group 1 = 30, group 2 = 30, and group 3 = 42). We found no significant difference between the three groups in terms of BMI, age, gravidity, parity, birth week, birth weight, interventional birth, perineal trauma, breastfeeding, duration of labor, oxytocin, IL-1 and IL-6 levels (p > 0.05). Neonatal intensive care unit (NICU) need, TAS, TOS, and copeptin levels were higher. Apgar scores were lower in the epidural group (p = 0.011, p = 0.036, p = 0.027, p < 0.001, and p < 0.001 respectively). Conclusion: Epidural analgesia has deteriorated oxidative stress status and lower neonatal Apgar scores with higher NICU administration compared with water birth and vaginal birth without pain relief.

Predictors of obstetric anal sphincter injury during waterbirth: a secondary analysis of a prospective observational study.

INTRODUCTION AND HYPOTHESIS: Obstetric anal sphincter injury (OASI) during childbirth is associated with urino-genital pain and dysfunction. Waterbirth is a popular birth choice for women, but controversy remains around the risk of OASI during waterbirth. This study reports on the incidence of OASI, and factors associated with OASI, for a cohort of women who gave birth in water. METHODS: This secondary analysis used prospectively collected data from 2,908 women who gave birth in water in a hospital setting. The incidence of OASI was calculated. Univariable and multivariable logistic regression analysis evaluated factors associated with OASI. RESULTS: The incidence of OASI was 1.9% (95% confidence interval (CI) 1.4, 2.4) for all women. In nulliparae it was higher (3.2%, 95% CI 2.3, 4.3) than in multiparae (0.9%, 95% CI 0.5, 1.4). In the multivariable analysis, two variables were associated with OASI; multiparity was negatively associated with OASI (adjusted odds ratio [aOR] 0.24, 95% CI 0.12, 0.50, p < 0.001), and birth weight was positively associated with OASI (aOR 1.001, 95% CI 1.000, 1.002, p = 0.02). A "hands-on" technique was used during only 13% of births. A birth position supporting a flexible sacrum did not influence OASI risk. CONCLUSIONS: A low incidence of OASI was found for this cohort of women. The low proportion of midwives using a hands-on technique suggests that it may not be required in waterbirth.

Women's experiences of planning a vaginal birth after caesarean in different models of maternity care in Australia.

BACKGROUND: Vaginal birth after caesarean (VBAC) is a safe mode of birth for most women but internationally VBAC rates remain low. In Australia women planning a VBAC may experience different models of care including continuity of care (CoC). There are a limited number of studies exploring the impact and influence of CoC on women's experiences of planning a VBAC. Continuity of care (CoC) with a midwife has been found to increase spontaneous vaginal birth and decrease some interventions. Women planning a VBAC prefer and benefit from CoC with a known care provider. This study aimed to explore the influence, and impact, of continuity of care on women's experiences when planning a VBAC in Australia. METHODS: The Australian VBAC survey was designed and distributed via social media. Outcomes and experiences of women who had planned a VBAC in the past 5 years were compared by model of care. Standard fragmented maternity care was compared to continuity of care with a midwife or doctor. RESULTS: In total, 490 women completed the survey and respondents came from every State and Territory in Australia. Women who had CoC with a midwife were more likely to feel in control of their decision making and feel their health care provider positively supported their decision to have a VBAC. Women who had CoC with a midwife were more likely to have been active in labour, experience water immersion and have an upright birthing position. Women who received fragmented care experienced lower autonomy and lower respect compared to CoC. CONCLUSION: This study recruited a non-probability based, self-selected, sample of women using social media. Women found having a VBAC less traumatic than their previous caesarean and women planning a VBAC benefited from CoC models, particularly midwifery continuity of care. Women seeking VBAC are often excluded from these models as they are considered to have risk factors. There needs to be a focus on increasing shared belief and confidence in VBAC across professions and an expansion of midwifery led continuity of care models for women seeking a VBAC.

A retrospective comparison of waterbirth outcomes in two United States hospital settings.

BACKGROUND: Water immersion during labor is an effective comfort measure; however, outcomes for waterbirth in the hospital setting have not been well documented. Our objective was to report the outcomes from two nurse-midwifery services that provide waterbirth within a tertiary care hospital setting in the United States. METHODS: This study is a retrospective, observational, matched comparison design. Data were collected from two large midwifery practices in tertiary care centers using information recorded at the time of birth for quality assurance purposes. Land birth cases were excluded if events would have precluded them from waterbirth (epidural, meconium stained fluid, chorioamnionitis, estimated gestational age < 37 weeks, or body mass index > 40). Neonatal outcomes included Apgar score and admission to the neonatal intensive care unit. Maternal outcomes included perineal lacerations and postpartum hemorrhage. RESULTS: A total of 397 waterbirths and 2025 land births were included in the analysis. There were no differences in outcomes between waterbirth and land birth for Apgar scores or neonatal intensive care admissions (1.8% vs 2.5%). Women in the waterbirth group were less likely to sustain a first- or second-degree laceration. Postpartum hemorrhage rates were similar for both groups. Similar results were obtained using a land birth subset matched on insurance, hospital location, and parity using propensity scores. DISCUSSION: In this study, waterbirth was not associated with increased risk to neonates, extensive perineal lacerations, or postpartum hemorrhage. Fewer women in the waterbirth group sustained first- or second-degree lacerations requiring sutures.

Waterbirth in low-risk pregnancy: An exploration of women's experiences.

AIMS: To explore retrospective descriptions about benefits, negative experiences and preparatory information related to waterbirths. DESIGN: A qualitative study. METHODS: Women who gave birth in water with healthy pregnancies and low-risk births were consecutively recruited between December 2015-October 2018 from two birthing units in Sweden. All who gave birth in water during the recruitment period were included (N = 155) and 111 responded to the survey. Women were emailed a web-based survey six weeks postpartum. Open-ended questions were analysed with qualitative content analysis. RESULTS: Two themes were identified related to benefits: (a) physical benefits: the water eases labour progression while offering buoyancy and pain relief; and (b) psychological benefits: improved relaxation and control in a demedicalized and safe setting. Two themes were identified related to negative experiences: (a) equipment-related issues due to the construction of the tub and issues related to being immersed in water; and (b) fears and worries related to waterbirth. In regard to preparatory information, respondents reported a lack of general and specific information related to waterbirths, even after they contacted birthing units to ask questions. Supplemental web-based information was sought, but the trustworthiness of these sources was questioned and a need for trustworthy web-based information was articulated. CONCLUSION: Women who give birth in water experience physical and psychological benefits, but need better equipment and sufficient information. There is room for improvement with regard to prenatal and intrapartum care of women who give birth in water. IMPACT: Judging from women's recounts, midwives and nurses should continue advocating waterbirth in low-risk pregnancies. The lack of adequate equipment in Swedish birthing units articulated by women challenge current routines and resources. The findings illustrate unfulfilled needs for preparatory information about waterbirth, further strengthening that midwives should discuss the possibility of waterbirth when meeting expectant parents in the antenatal setting.

Waterbirth in Sweden - a comparative study.

INTRODUCTION: The literature describes advantages for mothers giving birth in water, but waterbirth is controversial in Sweden and has not been offered at hospitals until recently. This study aimed to describe and compare the characteristics and outcome of waterbirths with those of spontaneous vaginal births at the same clinics. MATERIAL AND METHODS: A retrospective cohort study was conducted on all waterbirths at two maternity units in Sweden from March 2014 to November 2015 (n = 306), and a consecutively selected comparison group of 306 women having conventional spontaneous vaginal births. Logistic regression was used to analyze the primary outcome; second-degree perineal tears. RESULTS: Women giving birth in water had a lower risk of second-degree perineal tears [adjusted odds ratio (aOR) 0.6, 95% confidence interval (CI) 0.4-0.9]). Their labor was shorter (6 h 3 min vs. 7 h 52 min) and there were significantly fewer interventions than in the comparison group; amniotomy (13.7 vs. 35.3%), internal cardiotocography (11.1 vs. 56.8%), and augmentation with oxytocin (5.2 vs. 31.3%). There were no differences in Apgar scores or admissions to neonatal intensive care unit. The experience of childbirth, measured with a numeric rating scale, was higher in the waterbirth group indicating a more positive birth experience. Three newborns born in water had an umbilical cord avulsion. CONCLUSIONS: In this low-risk population, waterbirth is associated with positive effects on perineal tears, the frequency of interventions, the duration of labor and women's birth experience. Midwives handling waterbirth should be aware of the risk of umbilical cord avulsion.

Midwives' experience of their education, knowledge and practice around immersion in water for labour or birth.

BACKGROUND: There is limited research examining midwives' education, knowledge and practice around immersion in water for labour or birth. Our aim was to address this gap in evidence and build knowledge around this important topic. METHODS: This mixed method study was performed in two phases, between August and December 2016, in the birth centre of a tertiary public maternity hospital in Western Australia. Phase one utilised a cross sectional design to examine perceptions of education, knowledge and practice around immersion in water for labour or birth through a questionnaire. Phase two employed a qualitative descriptive design and focus groups to explore what midwives enjoyed about caring for women who labour or birth in water and the challenges midwives experienced with waterbirth. Frequency distributions were employed for quantitative data. Thematic analysis was undertaken to extract common themes from focus group transcripts. RESULTS: The majority (85%; 29 of 34) of midwives surveyed returned a questionnaire. Results from phase one confirmed that following training, 93% (27 of 29) of midwives felt equipped to facilitate waterbirth and the mean waterbirths required to facilitate confidence was seven. Midwives were confident caring for women in water during the first, second and third stage of labour and enjoyed facilitating water immersion for labour and birth. Finally, responses to labour and birth scenarios indicated midwives were practicing according to state-wide clinical guidance. Phase two included two focus groups of seven and five midwives. Exploration of what midwives enjoyed about caring for women who used water immersion revealed three themes: instinctive birthing; woman-centred atmosphere; and undisturbed space. Exploration of the challenges experienced with waterbirth revealed two themes: learning through reflection and facilities required to support waterbirth. CONCLUSIONS: This research contributes to the growing knowledge base examining midwives' education, knowledge and practice around immersion in water for labour or birth. It also highlights the importance of exploring what immersion in water for labour and birth offers midwives, as this research suggests they are integral to sustaining waterbirth as an option for low risk women.

The perceptions and experiences of women who achieved and did not achieve a waterbirth.

BACKGROUND: There is a gap in knowledge and understanding relating to the experiences of women exposed to the opportunity of waterbirth. Our aim was to explore the perceptions and experiences of women who achieved or did not achieve their planned waterbirth. METHODS: An exploratory design using critical incident techniques was conducted between December 2015 and July 2016, in the birth centre of the tertiary public maternity hospital in Western Australia. Women were telephoned 6 weeks post birth. Demographic data included: age; education; parity; and previous birth mode. Women were also asked the following: what made you choose to plan a waterbirth?; what do you think contributed to you having (or not having) a waterbirth?; and which three words would you use to describe your birth experience? Frequency distributions and univariate comparisons were employed for quantitative data. Thematic analysis was undertaken to extract common themes from the interviews. RESULTS: A total of 31% (93 of 296) of women achieved a waterbirth and 69% (203 of 296) did not. Multiparous women were more likely to achieve a waterbirth (57% vs 32%; p < 0.001). Women who achieved a waterbirth were less likely to have planned a waterbirth for pain relief (38% vs 52%; p = 0.24). The primary reasons women gave for planning a waterbirth were: pain relief; they liked the idea; it was associated with a natural birth; it provided a relaxing environment; and it was recommended. Two fifths (40%) of women who achieved a waterbirth suggested support was the primary reason they achieved their waterbirth, with the midwife named as the primary support person by 34 of 37 women. Most (66%) women who did not achieve a waterbirth perceived this was because they experienced an obstetric complication. The words women used to describe their birth were coded as: affirming; distressing; enduring; natural; quick; empowering; and long. CONCLUSIONS: Immersion in water for birth facilitates a shift of focus from high risk obstetric-led care to low risk midwifery-led care. It also facilitates evidence based, respectful midwifery care which in turn optimises the potential for women to view their birthing experience through a positive lens.

Obstetric and neonatal outcomes for women intending to use immersion in water for labour and birth in Western Australia (2015-2016): A retrospective audit of clinical outcomes.

BACKGROUND: Research supports water immersion for labour if women are healthy, with no obstetric or medical risk factors. AIMS: To evaluate the obstetric and neonatal outcomes of women intending to use immersion in water for labour or birth. METHODS: Retrospective audit of clinical outcomes for women intending to labour or birth in water conducted between July 2015 and June 2016, at a tertiary maternity hospital in Western Australia. Obstetric and neonatal data were collected from medical records. Multivariable logistic regression was utilised to investigate women who laboured in water stratified by those who birthed in water. RESULTS: A total of 502 women intended to labour or birth in water; 199 (40%) did not and 303 (60%) did. The majority of women using water immersion (179 of 303; 59%) birthed in water. Multiparous women were more likely than primparous to birth in water (73% vs 46%; P < 0.001). Women who birthed in water were at increased odds of: a first stage labour ≤240 min (odds ratio (OR) 2.56, 95% CI 1.34-4.87, P = 0.004); a second stage ≤60 min (OR 3.53, 95% CI 1.82-6.84, P < 0.000); a third stage labour of 11-30 min (OR 2.15, 95% CI 1.23-3.78, P = 0.008); and having an intact perineum (OR 3.10, 95% CI 1.70-5.64, P < 0.000). CONCLUSION: Not all women who set out to labour and birth in water achieve their aim. There is a need for high-quality collaborative research into this option of labour and birth, so women can make an informed choice around this birth option.

Perineal injuries and birth positions among 2992 women with a low risk pregnancy who opted for a homebirth.

BACKGROUND: Whether certain birth positions are associated with perineal injuries and severe perineal trauma (SPT) is still unclear. The objective of this study was to describe the prevalence of perineal injuries of different severity in a low-risk population of women who planned to give birth at home and to compare the prevalence of perineal injuries, SPT and episiotomy in different birth positions in four Nordic countries. METHODS: A population-based prospective cohort study of planned home births in four Nordic countries. To assess medical outcomes a questionnaire completed after birth by the attending midwife was used. Descriptive statistics, bivariate analysis and logistic regression were used to analyze the data. RESULTS: Two thousand nine hundred ninety-two women with planned home births, who birthed spontaneously at home or after transfer to hospital, between 2008 and 2013 were included. The prevalence of SPT was 0.7 % and the prevalence of episiotomy was 1.0 %. There were differences between the countries regarding all maternal characteristics. No association between flexible sacrum positions and sutured perineal injuries was found (OR 1.02; 95 % CI 0.86-1.21) or SPT (OR 0.68; CI 95 % 0.26-1.79). Flexible sacrum positions were associated with fewer episiotomies (OR 0.20; CI 95 % 0.10-0.54). CONCLUSION: A low prevalence of SPT and episiotomy was found among women opting for a home birth in four Nordic countries. Women used a variety of birth positions and a majority gave birth in flexible sacrum positions. No associations were found between flexible sacrum positions and SPT. Flexible sacrum positions were associated with fewer episiotomies.

Effects of Hydrotherapy on the Management of Childbirth and Its Outcomes-A Retrospective Cohort Study.

The use of hydrotherapy during childbirth has gained relevance due to the demand for natural childbirth and greater respect for the woman's choice. Studies have shown benefits such as less use of epidural analgesia, increased ability to cope with pain, shorter labor, and a better overall birth experience. OBJECTIVE: The main objective of this study was to generate further evidence on maternal and birth outcomes associated with the use of hydrotherapy during labor, specifically aiming to describe the effects of water immersion during all stages of labor (first, second, and third) on women. METHODOLOGY: A retrospective cohort study was carried out on a random sample of women who gave birth at the Costa del Sol Hospital between January 2010 and December 2020. The calculated sample size was 377 women and the data were extracted from their partograms. After data extraction, two groups were formed: one group used hydrotherapy during childbirth (n = 124), while the other group included women who did not use hydrotherapy during the childbirth process (n = 253). RESULTS: The results highlight significant differences in pain perception, analgesia use, types of labor, and delivery times between the two groups. Women who did not use hydrotherapy reported higher pain perception, with a median (IQR) of 8 (7-9) on a numerical scale, compared to a median (IQR) of 6 (5-7) for the hydrotherapy group. Furthermore, the group without hydrotherapy required epidural analgesia in 40% of cases, while in the hydrotherapy group, it was only necessary in 20%. In terms of the type of delivery, the hydrotherapy group had more spontaneous vaginal deliveries compared to the non-hydrotherapy group, which had more operative vaginal deliveries. The overall duration of labor was longer in the hydrotherapy group, especially in women who arrived at the hospital late in labor. CONCLUSIONS: Hydrotherapy is associated with a longer time to delivery. Women with a higher pain tolerance tend to opt for hydrotherapy instead of epidural analgesia.