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opinion and published in journals that are not peer reviewed.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
http://www.waterbirth.org/assets/documents/rcog_rcm_birth_in_water.pdf
accessed May 8, 2016.
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