|Year : 2018 | Volume
| Issue : 3 | Page : 111-115
Effect of water immersion on labor outcomes: A randomized clinical trial
Fatemeh Darsareh1, Shahla Nourbakhsh2, Fateme Dabiri3
1 Mother and Child Welfare Research Center, Hormozgan University of Medical Sciences; Social Determinants in Health Promotion Research Center, Hormozgan Health Institute, Hormozgan University of Medical Sciences, Bandar Abbas, Iran
2 Medical manegment department, Medical Chancellor of Social Security Organization, Hormozgan, Iran
3 Mother and Child Welfare Research Center, Hormozgan University of Medical Sciences, Bandar Abbas, Iran
|Date of Web Publication||29-Jun-2018|
PO Box 7919783141, Bandar Abbas
Source of Support: None, Conflict of Interest: None
Background: Water immersion during labor is increasingly being used in different medical facilities worldwide. Objective: This study aimed to determine the effects of water immersion during the first stage of labor on labor outcomes. Methods: This randomized controlled clinical trial was carried out from January to October 2015, in the labor and delivery ward of Khaleej-e Fars Hospital, Bandar Abbas, Iran. In total, 180 women were randomly allocated to a control group to receive routine care services and to an experimental group to receive water immersion during labor along with routine care services. The midwifery staff of the study setting regularly assessed uterine contractions, performed vaginal examinations, and monitored fetal heart rate. The length of the active phase of labor was measured in minutes as primary outcome. The independent-sample t and Chi-square tests were performed for data analysis. Results: The length of the active phase of labor in the experimental group was significantly greater than the control group (232.95 ± 20.76 vs. 165.81 ± 22.76 min; P < 0.001). Moreover, satisfaction with birth experience was significantly higher among women in the experimental group. However, no statistically significant between-group differences were observed in terms of the length of the second stage of labor, mode of delivery, the rate of hospitalization in neonatal intensive care unit, and 1- and 5-min Apgar scores (P > 0.05). Conclusions: Water immersion during labor significantly prolongs the first stage of labor and significantly improves parturient women's satisfaction with the birth experience.
Keywords: Delivery, Obstetric, Labor, Water
|How to cite this article:|
Darsareh F, Nourbakhsh S, Dabiri F. Effect of water immersion on labor outcomes: A randomized clinical trial. Nurs Midwifery Stud 2018;7:111-5
|How to cite this URL:|
Darsareh F, Nourbakhsh S, Dabiri F. Effect of water immersion on labor outcomes: A randomized clinical trial. Nurs Midwifery Stud [serial online] 2018 [cited 2020 Jan 29];7:111-5. Available from: http://www.nmsjournal.com/text.asp?2018/7/3/111/235639
| Introduction|| |
Different strategies are used during labor to manage labor pain, facilitate labor progression, shorten labor length, and most importantly, decrease labor complications without exerting any adverse effects on the mother and the neonate. Such strategies can also improve women's control over labor and satisfaction with it. One of these strategies is water immersion.
There is a wide range of water immersion techniques for labor. The main component of all these techniques is to stay in water during labor. The use of water immersion during labor is progressively increased in different areas of the world. It is currently an accessible method for empowering women for labor.
As an efficient nonpharmacological modality, water immersion during labor can promote relaxation, alleviate pain and stress, improve mother's satisfaction with labor, and improve maternal and neonatal outcomes. Warm water immersion can relax muscles, promote mental relaxation, and thereby, increase uterine blood flow, strengthen uterine contractions, promote uterine relaxation between contractions, and finally, shorten labor.
Water immersion was first used in 1973 in a hospital in France. Since then, different investigations were performed to determine its advantages and disadvantages for both mothers and neonates., For instance, a systematic review of eight published studies conducted on 2939 women showed that the use of water immersion in the first stage of labor can alleviate pain and reduce the need for analgesics without increasing the need for emergency cesarean section or negatively affecting labor length and neonatal outcomes. A randomized clinical trial also showed lower levels of pain and shorter labor length among women who gave birth in water. However, most studies on the effects of water immersion during labor are observational,, and there is a paucity of well-designed large-scale clinical trials in this area. Besides, the results of the available studies are contradictory, and hence, limited evidence exists regarding the effects of water immersion on labor length.,
In Iran, several birth centers have been established in the last 10 years for offering water immersion services to parturient women. However, controversies and concerns still exist over the safety and the effectiveness of water immersion. Therefore, further studies are needed to determine whether water immersion can be beneficial for parturient women.
This study aimed to determine the effects of water immersion during the first stage of labor on labor outcomes.
| Methods|| |
This randomized controlled clinical trial was conducted in January 2015–October 2015, in the labor and delivery ward of Khaleej-e Fars hospital, Bandar Abbas, Iran. On average, 500 neonates are born each month in the setting.
Sample size was calculated using a Type I error of 0.05, a power of 0.80, and an effect size of 0.30. Accordingly, through the G* Power statistical power analysis software SPSS v.18.0 (IBM Corp., Armonk, NY, USA), 82 women per group were estimated to be needed. Considering an attrition rate of 10%, sample size was set at ninety per group. Therefore, 180 women were recruited to the study and randomly assigned to either an experimental (n = 90) or a control (n = 90) group. Randomization was carried out using identical consecutively-numbered sealed envelopes. Each envelope indicated allocation sequence with an allocation ratio of 1:1.
Women who met the following eligibility criteria were included in the study: an age of 18–35 years; nulliparity; full-term singleton pregnancy; a cephalic fetal presentation; a cervical dilation of four centimeters; intact amniotic membranes on admission; >3 uterine contractions every 10 min; no serious chronic health problems; no obstetric complications; no abnormal clinical findings on physical examination; written informed consent for water immersion during labor; and agreement to participate in the study. Exclusion criteria were vaginal bleeding, uterine dysfunction, any sign of meconium in amniotic fluid, and any sign of fetal distress.
Among 2759 women, who gave birth in the study setting during the study, 437 (15.8%) met the eligibility criteria and were invited to the study. However, 257 were excluded and the remaining 180 women were randomly allocated to the study groups.
Women in the intervention group were subjected to water immersion during the first stage of labor. The immersion tub in this study was oval-shaped (size: 1.30 * 1.05 meters; depth: 0.65). Clean and filtered water (at a temperature of 37°C-37.5°C) was pumped into the tub from water mains during the first stage of labor and simultaneously was drained out. At the beginning of the active phase of labor (as determined by a cervical dilation of four centimeters), each woman entered the tub and sat in it while the water line was up to her nipple line. She remained in the tub until the end of the first stage, i.e. when cervical dilation was ten centimeters. After that, she came out of the tub, moved to her bed, and received routine care services. While sitting in the tub, midwifery staff of the study setting regularly assessed uterine contractions, performed vaginal examinations, and monitored fetal heart rate using a waterproof Sonicaid. Vaginal examinations were done every 1–2 h. Moreover, uterine contractions were evaluated every 30 min. Women with inadequate uterine contractions were provided with labor augmentation using five units of oxytocin in 1000 ml of Ringer's solution. Women in the control group received the same care services as their counterparts in the intervention group with the exception of water immersion. The first author was present in the study setting throughout each participant's entire labor. All participants, irrespective of their study groups, received individualized care during labor from the first author, while antenatal care were provided by the midwives of the study setting.
The primary outcome in this study was the length of the active phase of labor, which was defined as the time period between a cervical dilation of four to ten centimeters. It was measured and documented in participants' medical records by the clinicians in the study setting. Secondary outcomes were the length of the second stage of labor, mode of delivery (i.e., normal vaginal or operative vaginal), perineal conditions (intact, episiotomy, first- to fourth-degree laceration), need for augmentation with oxytocin, neonatal outcomes, 1- and 5-min Apgar scores, need for resuscitation and hospitalization in neonatal intensive care unit (from the time of birth to hospital discharge), and maternal satisfaction with birth experience. The latter was measured using a visual analog scale  which was a 10 cm line, the right and the left ends of which represented “No satisfaction” and “Extreme satisfaction,” respectively. The scale also included the following question, “Are you satisfied with your birth experience?” Each woman reported her satisfaction by placing a vertical mark on the scale. Satisfaction scores ranged from 0 to 10. We also assessed maternal age, body mass index before pregnancy, maternal weight gain, neonatal birth weight, and gestational age.
The Institutional Review Board and the Ethics Committee of Hormozgan University of Medical Sciences, Bandar Abbas, Iran, granted official approvals for this study (ethical approval code: HUMS.REC.1394.87). We attempted to protect participants' rights according to the Declaration of Helsinki. Verbal and written consents for water immersion were obtained from each participant in the intervention group by a midwife in the study setting, and then, she was asked to fill out and sign the informed consent form of the study. All participants were assured about the confidentiality of their personal information. This study obtained registration from the Iranian Registry of Clinical Trials (registration No. IRCT2015111725002N2).
Statistical data analyses were performed using the SPSS software v. 14.0 (SPSS Inc., Chicago, IL, USA). Numerical variables with normal distribution were summarized via mean and standard deviation, while numerical variables with nonnormal distribution were summarized through median and interquartile range (IQR: the difference between the first and the third quartiles). Categorical variables were also summarized through absolute and relative frequencies. Differences between the groups in terms of the numerical variables were examined through the independent-sample t test. Groups were also compared in terms of categorical variables through the Chi-square test. All statistical tests were two-tailed and were performed at a statistical significance level of <0.05.
| Results|| |
All 180 recruited women completed the study [Figure 1]. The groups were not significantly different from each other regarding maternal age, body mass index, weight gain, gestational age, and neonatal birth weight (P > 0.05; [Table 1]).
|Table 1: Comparison of the groups regarding maternal and neonatal characteristics|
Click here to view
The length of the active phase of labor in the experimental group was significantly greater than the control group (232.95 ± 20.76 vs. 165.81 ± 22.76 min; P < 0.001). However, no statistically significant difference was observed between the groups in terms of the length of the second stage of labor [Table 2].
|Table 2: Comparison of the groups regarding maternal and neonatal outcomes|
Click here to view
Most participants in both groups did not need labor augmentation and gave birth through spontaneous normal vaginal delivery. Moreover, none of the participants' neonates needed cardiopulmonary resuscitation. The groups did not significantly differ regarding the need for augmentation (P = 0.094), 1- and 5-min Apgar scores (P = 0.283 and 0.695, respectively), mode of delivery (P = 0.956), and neonates' hospitalization in neonatal intensive care unit (P = 0.747). However, compared with women in the control group, women in the experimental group had significantly greater satisfaction with birth experience (P < 0.001) [Table 2].
| Discussion|| |
In the present study, water immersion significantly increased the length of the active phase of labor. Some earlier prospective controlled studies also showed that water immersion did not significantly reduce the length of labor., Similarly, a systematic review showed that water immersion had no significant advantage over conventional labor. However, some other studies reported a significant decrease in the length of labor following water immersion.,, Another study also showed that if a parturient woman enters water before the onset of the active phase of labor or stay in water for >2 h, labor progress may be slowed down. This might be an explanation for the discrepancy between our findings and the findings reported in previous studies.
Our findings also indicated that water immersion had no significant impact on the need for augmentation, the length of the second stage of labor, and the mode of delivery. These findings are in line with the findings of previous studies., Moreover, although anecdotal reports show that the perineum can stretch more easily in water and hence may be less susceptible to traumas during labor, the results of the present study indicated no significant difference between groups in terms of perineal injury. This finding may be due to the fact that our participants were asked to leave the water tub at the beginning of the second stage of labor.
During labor, both parturient woman and her fetus are extremely vulnerable. Therefore, there are many controversies over the safety of interventions during labor and delivery, especially with the great focus of media on the adverse neonatal outcomes of water immersion. However, in line with the findings of an earlier study  and a Cochrane review on three randomized controlled trials, our findings revealed no significant between-group differences respecting neonatal outcomes such as 1- and 5-min Apgar scores and the rate of hospitalization in neonatal intensive care unit.
The results of the present study also indicated that women who used water immersion were significantly more satisfied with their birth experience. An earlier study also reported the same finding. A qualitative study on 189 women in England also reported that 81% of them were willing to use water immersion in their future deliveries and reported their experience of water immersion as relaxing, relieving, and confiding.
Labor and delivery require the integrated function of mind and body. In fact, mental status can significantly influence physical functioning. Some studies also reported that maternal confidence plays major roles in achieving optimum level of physiological functioning and having a normal delivery., Water immersion during labor can enhance mental status through decreasing catecholamine release, alleviating anxiety, improving endorphin release, and promoting muscle relaxation. Although some small-scale trials investigated the effects of water immersion during labor, further researches are still needed to provide firm evidence in this area.
There were some limitations in this study. First, women in the experimental group were treated in a setting different from that of those in the control group. The privacy and silence of that setting might have exerted some relaxing effects on women in the experimental group. Second, considering the characteristics of the study intervention, we were unable to keep participants and health-care providers in the study setting blind to the groups. Large-scale clinical trials are recommended to compare the effects of different water immersion protocols on maternal and neonatal outcomes and thereby, to determine the best water immersion protocol for labor.
| Conclusion|| |
This study reveals that although water immersion during labor is associated with greater length of labor, it significantly enhances satisfaction with the birth experience. Therefore, this technique can be used to enhance women's satisfaction with birth. This finding highlights the necessity to ensure not only the safety but also the pleasance of the birth experience.
We would like to thank the staff of labor and delivery ward of Khaleej-e Fars Hospital, Bandar Abbas, Iran and all pregnant women who participated in this study.
Financial support and sponsorship
The financial support for this study was provided by the Mother and Child Welfare Research Center of Hormozgan University of Medical Sciences, Bandar Abbas, Iran.
Conflicts of interest
There are no conflicts of interest.
| References|| |
Rathbun L. birth center model of care. JAMA 2017;317:645-6.
Royal College of Midwives. Royal College of Midwives. Campaign for Normal Birth. Royal College of Midwives; 2011. Available from: http://www.rcmnormalbirth.org.uk website
. [Last accessed on 2016 Sep 21].
The National Institute for Health and Care Excellence. Intrapartum care: Care of Healthy Women and their Babies During Childbirth; 2014. Available from: http://www.nice.org.uk/Guidance/CG190
. [Last accessed on 2017 Jun 21].
Harper B. Birth, bath, and beyond: The science and safety of water immersion during labor and birth. J Perinat Educ 2014;23:124-34.
Benfield RD, Hortobágyi T, Tanner CJ, Swanson M, Heitkemper MM, Newton ER, et al.
The effects of hydrotherapy on anxiety, pain, neuroendocrine responses, and contraction dynamics during labor. Biol Res Nurs 2010;12:28-36.
da Silva FM, de Oliveira SM, Nobre MR. A randomised controlled trial evaluating the effect of immersion bath on labour pain. Midwifery 2009;25:286-94.
Cluett ER, Burns E. Immersion in water in labour and birth. Cochrane Database Syst Rev 2009;2:CD000111.
Chaichian S, Akhlaghi A, Rousta F, Safavi M. Experience of water birth delivery in Iran. Arch Iran Med 2009;12:468-71.
Young K, Kruske S. How valid are the common concerns raised against water birth? A focused review of the literature. Women Birth 2013;26:105-9.
Cortes E, Basra R, Kelleher CJ. Waterbirth and pelvic floor injury: A retrospective study and postal survey using ICIQ modular long form questionnaires. Eur J Obstet Gynecol Reprod Biol 2011;155:27-30.
Garland D. Exploring carers' views and attitudes towards the use of water during labour and birth. MIDIRS Midwifery Digest 2011;21:193-6.
Brokelman RB, Haverkamp D, van Loon C, Hol A, van Kampen A, Veth R, et al.
The validation of the visual analogue scale for patient satisfaction after total hip arthroplasty. Eur Orthop Traumatol 2012;3:101-5.
Simpson KR. Underwater birth. J Obstet Gynecol Neonat Nurs 2013;42:588-94.
Rooks JP. Labor pain management other than neuraxial: What do we know and where do we go next? Birth 2012;39:318-22.
Enning C. How to support the autonomy of motherbaby in second stage of waterbirth. Midwifery Today Int Midwife 2011;98:40-1.
Byard RW, Zuccollo JM. Forensic issues in cases of water birth fatalities. Am J Forensic Med Pathol 2010;31:258-60.
Lewis L, Hauck YL, Butt J, Hornbuckle J. 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. Aust N
Z J Obstet Gynaecol 2018. doi: 10.1111/ajo.12758.
Menakaya U, Albayati S, Vella E, Fenwick J, Angstetra D. A retrospective comparison of water birth and conventional vaginal birth among women deemed to be low risk in a secondary level hospital in Australia. Women Birth 2013;26:114e8.
Thöni A, Mussner K, Ploner F. Water birthing: Retrospective review of 2625 water births. Contamination of birth pool water and risk of microbial cross-infection. Minerva Ginecol 2010;62:203-11.
Mammas IN, Thiagarajan P. Water aspiration syndrome at birth-report of two cases. J Matern Fetal Neonat Med 2009;22:365-7.
Burns EE, Boulton MG, Cluett E, Cornelius VR, Smith LA. Characteristics, interventions, and outcomes of women who used a birthing pool: A prospective observational study. Birth 2012;39:192-202.
Cordioli E. Immersion in water in labour and birth. Sao Paulo Med J 2013;131:364.
Carpenter L, Weston P. Neonatal respiratory consequences from water birth. J Paediatr Child Health 2012;48:419-23.
Bergman J. Hold your Preemie. Cape Town, Africa: New Voices; 2011.
[Table 1], [Table 2]