Immersion in water in the first stage of labour

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Immersion in water in the first stage of labour
Introduction
The Winterton report recommended that all maternity units should provide women with the option to labour and give birth in water. 81 However, the number of women actually using water during labour is not well reported. A survey between April 1994 and March 1996 identified 0.6% of births in England and Wales occurring in water,9% of which were home births. 140 There would appear to be a wide variation in the use of water during birth, with one birth centre reporting up to 80% of women using water during birth and up to 79% giving birth there. 141
Previous guideline
Water birth was reviewed in the NICE Caesarean Section guideline. (RCOG, 2004) The guideline reviewed one systematic review, one RCT and some other observational studies and recommended that women should be informed that immersion in water during labour has not been shown to influence the likelihood of CS, although it may affect other outcomes. [A]
Description of included studies National Collaborating Centre for Women’s and Children’s Health Page 262 of 675 Intrapartum care final draft for consultation
There was one systematic review and one RCT identified for inclusion in the review. The systematic review included 8 trials. 142 [EL 1+] Out of the 8 trials, 6 examined immersion in water in the first stage of labour, one examined immersion in water in the second stage of the labour, and one investigated the timing of the use of water in the first stage of labour. An additional RCT examined effectiveness of use of water in the first stage compared with augmentation. 143 [EL 1-]
Review findings
Use of water vs. other methods
Women’s outcomes
Meta-analysis of findings from 4 trials showed that the use of water in the first stage of labour reduces the use of epidural/spinal analgesia/anaesthesia (OR 0.84 [95% CI 0.71 to 0.99]). One trial reported significantly reduced reported pain for those women who laboured in water compared with those not labouring in water (OR 0.23, [95% CI 0.08 to 0.63]).
Meta-analysis of 4 trials showed no evidence of differences on duration of the first and second stages of labour. Six trials reported on instrumental delivery rates. Overall there was no evidence of any difference; instrumental vaginal delivery rate (OR for use of water 0.83, [95% CI 0.66 to 1.05]) and caesarean section rate (OR for use of water 1.33, [95% CI 0.92 to 1.91]). 142 [EL 1+] National Collaborating Centre for Women’s and Children’s Health Page 263 of 675 Intrapartum care final draft for consultation
There was no evidence of differences on perineal trauma with immersion in water during labour: episiotomy (OR 0.89, [95% CI 0.68 to 1.15]), second degree tears (OR 0.90 [95% CI 0.66 to 1.23]) and third/fourth degree tears (OR 1.38 [95% CI 0.85 to 2.24]).
Newborn outcomes
5 trials reported on APGAR scores at 5 minutes and there was no difference in the number of infants with a score of less than 7 at 5 minutes (OR 1.59 [95% CI 0.63 to 4.01]). 2 trials reported admissions to the neonatal unit and found no evidence of difference (OR 1.05 [95% CI 0.68 to 1.61]). Infection rates were reported in 4 trials and were found to be very low (6/629 versus 3/633; OR 2.01 [95% CI 0.50 to 8.07]).
Timing of use of water
One trial in the systematic review compared early versus late immersion during the first stage of labour, and found significantly higher epidural analgesia rates in the early group (42/100 versus 19/100; OR 3.09 [95% CI 1.63 to 5.84]) and an increased use of augmentation of labour (57/100 versus 30/100; OR 3.09 [95% CI 1.73 to 5.54]). 144
Augmentation vs. use of water
One trial compared augmentation versus immersion in water during the first stage of labour. 143 [EL 1-] It showed that use of water reduced rate of National Collaborating Centre for Women’s and Children’s Health Page 264 of 675 Intrapartum care final draft for consultation
augmentation (RR 0.74, p=0.001) and increased some aspects of satisfaction (freedom of movement MD 1.46, p=0.001; privacy MD 1.18, p=0.03, satisfaction with the care MD 1.07, p=0.49). There were more infants admitted to neonatal units with use of water (admission to neonatal unit 6/49(water), 0/50(air), p=0.01), but there is no evidence of a difference on cord arterial pH and infection rate (Cord arterial pH 7.26(water), 7.25(air), p=0.97; infection 8/49(water), 9/50(air), p=0.7[img]images/forum/icons/icon_cool.gif[/img].
Evidence statement
Immersion in water in the first stage reduces pain and the use of regional analgesia. There is no evidence of differences regarding adverse outcomes when comparing labours with and without the use of water. There is insufficient evidence on timing of use of water in labour.
Recommendations
Women should be offered immersion in water as it reduces pain and the numbers of women having an epidural without evidence of harm to the baby. [A]
The temperature of the water should be monitored such that the woman is comfortable and not pyrexial – a temperature not above 37.5 Celsius degree. [GPP]