Sunday, May 8, 2016

Water Birth or Land Birth! What is more safe for babies? A systemic review and meta-analysis.

Immersion in water during labor or delivery has gained popularity in recent years in many parts of world and has been suggested as a better alternative to delivering in hospital labor wards.

Many Hospitals in U.K are offering women a choice between traditional hospital delivery vs laboring in water. In fact, a 2006 joint statement from the Royal College of Obstetricians and Gynaecologists and Royal College of Midwives supported immersion in water during labor for uncomplicated pregnancies and stressed that the organization should provide infrastructure and system to develop best practice for underwater birthing.

A latest review published on April 28, in online edition of Archives of Disease inChildhood - Fetal and Neonatal Edition quotes that in U.K.  about 9% of total deliveries occurred under water in year 2015.

Professor Alastair Sutcliffe and his colleagues conducted a systemic review and meta-analysis and pooled the data from 29 studies amounting a total of 39,000 labors.

All these studies were small, observational studies conducted mostly at small hospitals in Europe and other wealthy countries. They are many a time based on personal opinion and published in journals that are not peer reviewed. The studies also differ on the way the labor is conducted and “underwater” in some studies meant only the first stage in water and other included the second stage underwater too.

However, in these studies it was observed that the babies did have slightly higher Apgar scores but the difference was not significant.

There are many perceived benefits of labor underwater less painful contractions and less need for pharmacological analgesia, shorter labor, less need for augmentation. A 2009 Cochrane systemic review of RCTs involving   immersion in the first stage of labor documented no such benefits. Only the need for epidural, spinal or paracervical anesthesia was slightly reduced in study group. But, the incidence of perineal trauma or tears remained the same in the two groups.

No increased fetal respiratory complications were seen in these review which reported “there is no evidence of increased adverse effects to the fetus/neonate or woman from laboring in water or water birth.”

Several other small studies and case reports have reported higher risk of maternal and neonatal infections, particularly with ruptured membranes; difficulties in neonatal thermoregulation; Umbilical cord avulsion; severe respiratory distress, increased NICU admissions and tub water aspiration.
However, the present study as well as 2009 Cochrane review did not report any of these increased neonatal complications.

RCOG and Royal college of Midwives U.K advocate that “All healthy women with uncomplicated pregnancies at term should have the option of water birth available to them and should be able to proceed to a water birth if they wish.” 

In the U.S., however, the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics recommend against underwater deliveries due to potential complications for babies such as infections, breathing difficulties and drowning.

ACOG does take an equivocal stance on immersion during first stage of labor, which may   be associated with decreased pain or use of anesthesia and decreased duration of labor. However, it stresses the need of routine maternal and fetal monitoring even if the mother is in birthing pool/tub.
It does not support the second stage of labor underwater and only advocates its use in context of clinical trials as an experimental procedure with written consent.  

ACOG also insist the need of rigorous protocols for candidate selection to maintenance and cleaning of tubs and immersion pools, infection control procedures, monitoring of mothers and fetuses at appropriate intervals while immersed, and protocols for moving women from tubs if urgent maternal or fetal concerns develop.

In all, the current review and meta-analysis failed to document that underwater labor is safe or unsafe and Dr. Alastair Sutcliffe opines that “Whilst it is a good plan to try labor in water, my advice is to wait until there is more convincing evidence of safety before having the actual delivery in water."



References:
Cluett ER, Burns E. Immersion in water in labour and birth. Cochrane Database of Systematic Reviews 2009, Issue 2. Art. No.: CD000111


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