Dr Ethel Burns

Aims.

To identify and synthesize the evidence regarding the facilitators and barriers relating to birthing pool use from organizational and multi‑professional perspectives. 

Design. 

A systematic integrated mixed methods review was conducted. Data sources MEDLINE, CINAHL, PsychINFO, EMCARE, PROQUEST, and Web of Science databases were searched in April 2021, March 2022, and April 2024. We cross‑referenced with Google Scholar and undertook reference list searches. 

Review methods.

Data were extracted from studies meeting the inclusion criteria. Barriers and facilitators to birthing pool use were mapped and integrated into descriptive statements further synthesized to develop overarching themes. 

Results.

Thirty-seven articles (29 studies) were included—quantitative (12), qualitative (8), mixed methods (7), and audits (2), from 12 countries. These included the views of 9,082 multi‑professionals (midwives, nurses, obstetricians, neonatologists, students, physicians, maternity support workers, doulas, and childbirth educators). Additionally, 285 institutional policies or guidelines were included in 9 papers and 1 economic evaluation. Five themes were generated: The paradox of prescriptiveness, The experienced but elusive practitioner, Advocacy and tensions, Trust or Trepidation and It’s your choice, but only if it is a choice. These revealed when personal, contextual, and infrastructural factors were aligned and directed towards the support of birth pool use, birthing pool use was a genuine option. Conversely, the more barriers that women and midwives experienced, the less likely it was a viable option, reducing choice and access to safe analgesia. 

Conclusion.

The findings demonstrated a paradoxical reality of water immersion with each of the five themes detailing how the “swing” within these factors directly affected whether birthing pool use was facilitated or inhibited.

Abstract

Objectives 
Water immersion during labour using a birth pool to achieve relaxation and pain relief during the first and possibly part of the second stage of labour is an increasingly popular care option in several countries. It is used particularly by healthy women who experience a straightforward pregnancy, labour spontaneously at term gestation and plan to give birth in a midwifery led care setting. More women are also choosing to give birth in water. There is debate about the safety of intrapartum water immersion, particularly waterbirth. We synthesised the evidence that compared the effect of water immersion during labour or waterbirth on intrapartum interventions and outcomes to standard care with no water immersion. A secondary objective was to synthesise data relating to clinical care practices and birth settings that women experience who immerse in water and women who do not.

Design 
Systematic review and meta-analysis.

Data sources 
A search was conducted using CINAHL, Medline, Embase, BioMed Central and PsycINFO during March 2020 and was replicated in May 2021.

Eligibility criteria for selecting studies 
Primary quantitative studies published in 2000 or later, examining maternal or neonatal interventions and outcomes using the birthing pool for labour and/or birth.

Data extraction and synthesis 
Full-text screening was undertaken independently against inclusion/exclusion criteria in two pairs. Risk of bias assessment included review of seven domains based on the Robbins-I Risk of Bias Tool. All outcomes were summarised using an OR and 95% CI. All calculations were conducted in Comprehensive Meta-Analysis V.3, using the inverse variance method. Results of individual studies were converted to log OR and SE for synthesis. Fixed effects models were used when I2 was less than 50%, otherwise random effects models were used. The fail-safe N estimates were calculated to determine the number of studies necessary to change the estimates. Begg’s test and Egger’s regression risk assessed risk of bias across studies. Trim-and-fill analysis was used to estimate the magnitude of effect of the bias. Meta-regression was completed when at least 10 studies provided data for an outcome.

Results 
We included 36 studies in the review, (N=157 546 participants). Thirty-one studies were conducted in an obstetric unit setting (n=70 393), four studies were conducted in midwife led settings (n=61 385) and one study was a mixed setting (OU and homebirth) (n=25 768). Midwife led settings included planned home and freestanding midwifery unit (k=1), alongside midwifery units (k=1), planned homebirth (k=1), a freestanding midwifery unit and an alongside midwifery unit (k=1) and an alongside midwifery unit (k=1). For water immersion, 25 studies involved women who planned to have/had a waterbirth (n=151 742), seven involved water immersion for labour only (1901), three studies reported on water immersion during labour and waterbirth (n=3688) and one study was unclear about the timing of water immersion (n=215).

Water immersion significantly reduced use of epidural (k=7, n=10 993; OR 0.17 95% CI 0.05 to 0.56), injected opioids (k=8, n=27 391; OR 0.22 95% CI 0.13 to 0.38), episiotomy (k=15, n=36 558; OR 0.16; 95% CI 0.10 to 0.27), maternal pain (k=8, n=1200; OR 0.24 95% CI 0.12 to 0.51) and postpartum haemorrhage (k=15, n=63 891; OR 0.69 95% CI 0.51 to 0.95). There was an increase in maternal satisfaction (k=6, n=4144; OR 1.95 95% CI 1.28 to 2.96) and odds of an intact perineum (k=17, n=59 070; OR 1.48; 95% CI 1.21 to 1.79) with water immersion. Waterbirth was associated with increased odds of cord avulsion (OR 1.94 95% CI 1.30 to 2.88), although the absolute risk remained low (4.3 per 1000 vs 1.3 per 1000). There were no differences in any other identified neonatal outcomes.

Conclusions 
​​​​​​​This review endorses previous reviews showing clear benefits resulting from intrapartum water immersion for healthy women and their newborns. While most included studies were conducted in obstetric units, to enable the identification of best practice regarding water immersion, future birthing pool research should integrate factors that are known to influence intrapartum interventions and outcomes. These include maternal parity, the care model, care practices and birth setting.

Introduction

Research to understand factors associated with normal physiological birth (unassisted vaginal birth, spontaneous labor onset without epidural, spinal or general anaesthetic, without episiotomy) is required. Laboring and/or giving birth in water has been shown to be associated with a high proportion of physiologic birth, but with little understanding of factors which may influence this outcome.  This study explored factors associated with normal physiological birth for women who labored in water.

Methods

We conducted a secondary analysis of a UK-based prospective observational study of 8,064 women at low risk of childbirth complications who labored in water. Consecutive women were recruited from birth settings in England, Scotland, and Northern Ireland. Planned place of birth, maternal characteristics, intrapartum events, maternal and neonatal outcomes were measured. Univariable and multivariable logistic regression modelling explored factors associated with normal physiological birth.

Results

In total, 5758 (71.4%) of women who labored in water had a normal physiological birth. Planned birth in the community [aOR 2.58, 95% CI 2.22-2.99] or at an alongside midwifery unit [aOR 1.21, 95% CI 1.04-1.41] was positively associated with normal physiological birth compared with planned birth in an obstetric unit. Duration of second stage [aOR 0.66, 95% CI 0.62–0.70], duration in the pool [aOR 0.93, 95% CI 0.90–0.96] and birth weight of the neonate [aOR 0.74, 95% CI 0.65–0.85] were negatively associated with normal physiological birth. Parity was not associated with normal physiological birth in multivariate analyses.

Discussion

Our findings largely reflected wider research, both in and out of water. We found midwifery-led birth settings may increase the likelihood of normal physiological birth among healthy women who labor in water, irrespective of parity. This association supports growing evidence demonstrating the importance of planned place of birth on reducing intervention rates, and adds to research on labor and birth in water.

Abstract

Aims: To gather, quality assess, synthesize and interpret the views, feeling, and experiences of women who used water immersion during labour and/or birth.

Design: A systematic meta-thematic synthesis and GRADE-CERQual.

Data sources: We searched MEDLINE, CINHAL, PsychINFO, AMED, EMBASE (MIDIRS only), LILACS, AJOL. Additional searches were carried out using Ethos (thesis database), cross-referencing against Google Scholar and citation chasing. Searches were carried out in August 2019, updated February 2020.

Methods: Studies that met the selection criteria were appraised for quality. Data were extracted from the studies using meta-thematic analytical techniques; coding, descriptive findings, and analytical findings. The descriptive findings were subjected to confidence assessments using GRADE-CERQual.

Results: Seven studies met the inclusion criteria. Nine key statements of findings were generated - one had high confidence, three moderate, three low and one very low confidence in the findings. The analytical findings generated three main themes: Liberation and Self-Emancipation, Synergy, transcendence and demarcation and Transformative birth and beyond. Overall, women experienced warm water immersion during labour and/or birth positively. Both the water and pool itself, facilitated women's physical and psychological needs during labour and/or birth, including offering effective analgesia. Our findings indicated that birthing pools are versatile tools that provide for a space that women can adapt and influence to best suit their individual needs.

Conclusion: Women who used warm water immersion for labour and/or birth describe liberating and transformative experiences of welcoming their babies into the world. They were empowered, liberated, and satisfied. We recommend maternity professionals and services offer water immersion as a standard method of pain relief during labour/birth.

Impact: Understanding women's experiences of labour and birth will inform future clinical practice. Midwives are optimally positioned to enhance women's access to water immersion. These findings have implications for education, guideline, and policy development as well as clinical practice.

Keywords: analgesia; birth pool; childbirth; maternity care; midwifery; nursing; pain relief; water.

Objectives. To describe the extent to which local guidelines for admission to UK midwifery units align with national guidance; to describe variation in individual admission criteria; and to describe the extent to which alongside midwifery units (AMUs) are the default option for eligible women.

Design. National cross-sectional survey.

Setting. All 122 UK maternity services with midwifery units, between October 2018 and February 2019.

Outcome measures. Alignment of local admission guidelines with national guidance (NICE CG190); frequency and nature of variation in individual admission criteria; percentage of services with AMU as default birth setting for eligible women.

Results. Admission guidelines were received from 87 maternity services (71%), representing 153 units, and we analysed 85 individual guideline documents. Overall, 92% of local admission guidelines varied from national guidance; 76% contained both some admission criteria that were ‘more inclusive’ and some that were ‘more restrictive’ than national guidance. The most common ‘more inclusive’ admission criteria, occurring in 40–80% of guidelines, were: explicit admission of women with parity ≥4; aged 35-40yrs; with a BMI 30-35kg/m2; selective admission of women with a BMI 35-40kg/m2; Group B Streptococcus carriers; and those undergoing induction of labour. The most common ‘more restrictive’ admission criteria, occurring in around 30% of guidelines, excluded women who: declined blood products; had experienced female genital cutting; were aged

Conclusions. The variation in local midwifery unit admission criteria found in this study represents a potentially confusing and inequitable basis for women making choices about planned place of birth. A review of national guidance may be indicated and where a lack of relevant evidence underlies variation in admission criteria, further research by planned place of birth is required.

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 the hospital setting. 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% CI 1.4, 2.4) for all women. In nulliparae it was higher (3.2%, 95% CI 2.3, 4.3), than for 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 (aOR 0.24, 95% CI 0.12, 0.50, p

In this fourth article of our Advancing practice education series, a novel initiative regarding the engagement of service-users to student midwife recruitment is outlined. Whilst the NMC mandates service user involvement, it can be challenging to implement. We at Oxford Brookes University introduced an initiative involving group discussions between candidates and service users. Feedback was sought via an evaluation form which 68 candidates and six service users completed. Candidates enjoyed the opportunity to question mothers in an informal group setting, and women felt valued through sharing their stories and making a meaningful contribution to the recruitment process.

Objective. To explore factors that influence parents' decision-making for mode of breech birth at term gestation. Design. A grounded theory study conducted using a constructivist approach. Semi-structured telephone interviews were recorded and transcribed verbatim and analysed using the software NVivo for Mac version 11.4.0. Setting. England, UK. Participants. Twelve parents with breech presentation confirmed by ultrasound at ≥36+0 weeks gestation were recruited from several UK social media forums. Findings. Two core themes impacting on a parent's decision-making process for term breech birth were identified. Firstly, a framework of potential influences including partner and relationship, family and friends, health professionals, own birth culture, self, shared experiences and the time available for decision-making. Secondly, mortality salience, or parental focus on risk of potential injury or death associated with birth, was found to be central to every participant's narrative. Key conclusions. This study highlights the individuality and wider framework of parent's decision-making influences for term breech birth, and demonstrates to care providers the conflicted emotions that may be experienced. The findings of this study may guide midwives and other professionals in providing person-centered, non-judgmental, balanced and evidence-based mode of term breech birth counselling. Implications for practice. Health professionals should adopt a parentcentred approach to counselling for mode of term breech birth, considering parents' wider influences in their decision-making and the fear of injury or death surrounding both vaginal breech birth and caesarean section. They can also facilitate parents to understand the influences that might be guiding their own decision-making.

Objective. The principal objective was to test the effectiveness of an online learning tool to improve midwives’ accuracy of blood loss estimations in a birthing pool environment. The secondary objective was to assess the acceptability of the online learning tool to the midwives using it. Design. A one group pre-test post-test experiment with immediate and six weeks follow-up to test ability together with an online questionnaire to assess perceived usefulness of an online learning tool. Setting. A large NHS maternity hospital comprising an acute care obstetric unit, a small district unit labour ward, one alongside midwifery-led unit and three freestanding midwifery-led units. Participants. Volunteer NHS employed midwives who had experience in caring for women labouring and giving birth in water (n=24). Intervention. An online learning tool comprising six randomly ordered short video simulations of blood loss in a birthing pool in real time, and a tutorial giving verbal and pictorial guidance on making accurate blood loss estimations in water was developed then piloted. Midwives’ accuracy scores for estimating blood loss in each of the videos were calculated at three timepoints; pre and immediately post the learning component, and six weeks later. The estimated blood loss volume was subtracted from the actual blood loss volume, to give the difference between estimated and real blood loss in millilitres(ml) which was then converted to percentage difference to standardise comparison across the six volumes. The differences between pre- and post-learning for each of the six blood volumes was analysed using a repeated measures ANOVA. Statistical significance was set at p

Background

Parenteral opioids (intramuscular and intravenous drugs including patient‐controlled analgesia) are used for pain relief in labour in many countries throughout the world. This review is an update of a review first published in 2010.

Objectives

To assess the effectiveness, safety and acceptability to women of different types, doses and modes of administration of parenteral opioid analgesia in labour. A second objective is to assess the effects of opioids in labour on the baby in terms of safety, condition at birth and early feeding.

Search methods

We searched Cochrane Pregnancy and Childbirth’s Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (11 May 2017) and reference lists of retrieved studies.

Selection criteria

We included randomised controlled trials examining the use of intramuscular or intravenous opioids (including patient‐controlled analgesia) for women in labour. Cluster‐randomised trials were also eligible for inclusion, although none were identified. We did not include quasi‐randomised trials. We looked at studies comparing an opioid with another opioid, placebo, no treatment, other non‐pharmacological interventions (transcutaneous electrical nerve stimulation (TENS)) or inhaled analgesia.

Data collection and analysis

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. We assessed the quality of each evidence synthesis using the GRADE approach.

Main results

We included 70 studies that compared an opioid with placebo or no treatment, another opioid administered intramuscularly or intravenously or compared with TENS applied to the back. Sixty‐one studies involving more than 8000 women contributed data to the review and these studies reported on 34 different comparisons; for many comparisons and outcomes only one study contributed data. All of the studies were conducted in hospital settings, on healthy women with uncomplicated pregnancies at 37 to 42 weeks' gestation. We excluded studies focusing on women with pre‐eclampsia or pre‐existing conditions or with a compromised fetus. Overall, the evidence was graded as low‐ or very low‐quality regarding the analgesic effect of opioids and satisfaction with analgesia; evidence was downgraded because of study design limitations, and many of the studies were underpowered to detect differences between groups and so effect estimates were imprecise. Due to the large number of different comparisons, it was not possible to present GRADE findings for every comparison.

For the comparison of intramuscular pethidine (50 mg/100 mg) versus placebo, no clear differences were found in maternal satisfaction with analgesia measured during labour (number of women satisfied or very satisfied after 30 minutes: 50 women; 1 trial; risk ratio (RR) 7.00, 95% confidence interval (CI) 0.38 to 128.87, very low‐quality evidence), or number of women requesting an epidural (50 women; 1 trial; RR 0.50, 95% CI 0.14 to 1.78; very low‐quality evidence). Pain scores (reduction in visual analogue scale (VAS) score of at least 40 mm: 50 women; 1 trial; RR 25, 95% CI 1.56 to 400, low‐quality evidence) and pain measured in labour (women reporting pain relief to be "good" or "fair" within one hour of administration: 116 women; 1 trial; RR 1.75, 95% CI 1.24 to 2.47, low‐quality evidence) were both reduced in the pethidine group, and fewer women requested any additional analgesia (50 women; 1 trial; RR 0.71, 95% CI 0.54 to 0.94, low‐quality evidence).

There was limited information on adverse effects and harm to women and babies. There were few results that clearly showed that one opioid was more effective than another. Overall, findings indicated that parenteral opioids provided some pain relief and moderate satisfaction with analgesia in labour. Opioid drugs were associated with maternal nausea, vomiting and drowsiness, although different opioid drugs were associated with different adverse effects. There was no clear evidence of adverse effects of opioids on the newborn. We did not have sufficient evidence to assess which opioid drug provided the best pain relief with the least adverse effects.

Authors' conclusions

Though most evidence is of low‐ or very‐low quality, for healthy women with an uncomplicated pregnancy who are giving birth at 37 to 42 weeks, parenteral opioids appear to provide some relief from pain in labour but are associated with drowsiness, nausea, and vomiting in the woman. Effects on the newborn are unclear. Maternal satisfaction with opioid analgesia was largely unreported. The review needs to be examined alongside related Cochrane reviews. More research is needed to determine which analgesic intervention is most effective, and provides greatest satisfaction to women with acceptable adverse effects for mothers and their newborn.

Background

Water immersion during labour and birth is increasingly popular and is becoming widely accepted across many countries, and particularly in midwifery‐led care settings. However, there are concerns around neonatal water inhalation, increased requirement for admission to neonatal intensive care unit (NICU), maternal and/or neonatal infection, and obstetric anal sphincter injuries (OASIS). This is an update of a review last published in 2011.

Objectives

To assess the effects of water immersion during labour and/or birth (first, second and third stage of labour) on women and their infants.

Search methods

We searched Cochrane Pregnancy and Childbirth’s Trials Register, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) (18 July 2017), and reference lists of retrieved trials.

Selection criteria

We included randomised controlled trials (RCTs) comparing water immersion with no immersion, or other non‐pharmacological forms of pain management during labour and/or birth in healthy low‐risk women at term gestation with a singleton fetus. Quasi‐RCTs and cluster‐RCTs were eligible for inclusion but none were identified. Cross‐over trials were not eligible for inclusion.

Data collection and analysis

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. Two review authors assessed the quality of the evidence using the GRADE approach.

Main results

This review includes 15 trials conducted between 1990 and 2015 (3663 women): eight involved water immersion during the first stage of labour; two during the second stage only; four during the first and second stages of labour, and one comparing early versus late immersion during the first stage of labour. No trials evaluated different baths/pools, or third‐stage labour management. All trials were undertaken in a hospital labour ward setting, with a varying degree of medical intervention considered as routine practice. No study was carried out in a midwifery‐led care setting. Most trial authors did not specify the parity of women. Trials were subject to varying degrees of bias: the intervention could not be blinded and there was a lack of information about randomisation, and whether analyses were undertaken by intention‐to‐treat.

Immersion in water versus no immersion (first stage of labour)

There is probably little or no difference in spontaneous vaginal birth between immersion and no immersion (83% versus 82%; risk ratio (RR) 1.01, 95% confidence interval (CI) 0.97 to 1.04; 6 trials; 2559 women; moderate‐quality evidence); instrumental vaginal birth (12% versus 14%; RR 0.86, 95% CI 0.70 to 1.05; 6 trials; 2559 women; low‐quality evidence); and caesarean section (5% versus 4%; RR 1.27, 95% CI 0.91 to 1.79; 7 trials; 2652 women; low‐quality evidence). There is insufficient evidence to determine the effect of immersion on estimated blood loss (mean difference (MD) ‐14.33 mL, 95% CI ‐63.03 to 34.37; 2 trials; 153 women; very low‐quality evidence) and third‐ or fourth‐degree tears (3% versus 3%; RR 1.36, 95% CI 0.85 to 2.18; 4 trials; 2341 women; moderate‐quality evidence). There was a small reduction in the risk of using regional analgesia for women allocated to water immersion from 43% to 39% (RR 0.91, 95% CI 0.83 to 0.99; 5 trials; 2439 women; moderate‐quality evidence). Perinatal deaths were not reported, and there is insufficient evidence to determine the impact on neonatal intensive care unit (NICU) admissions (6% versus 6%; average RR 1.30, 95% CI 0.42 to 3.97; 2 trials; 1511 infants; I² = 36%; low‐quality evidence), or on neonatal infection rates (1% versus 1%; RR 2.00, 95% CI 0.50 to 7.94; 5 trials; 1295 infants; very low‐quality evidence).

Immersion in water versus no immersion (second stage of labour)

There were no clear differences between groups for spontaneous vaginal birth (98% versus 97%; RR 1.02, 95% CI 0.96 to 1.08; 120 women; 1 trial; low‐quality evidence); instrumental vaginal birth (2% versus 2%; RR 1.00, 95% CI 0.06 to 15.62; 1 trial; 120 women; very low‐quality evidence); caesarean section (0% versus 2%; RR 0.33, 95% CI 0.01 to 8.02; 1 trial; 120 women; very low‐quality evidence), and NICU admissions (8% versus 11%; RR 0.78, 95% CI 0.38 to 1.59; 2 trials; 291 women; very low‐quality evidence). Use of regional analgesia was not relevant to the second stage of labour. Third‐ or fourth‐degree tears, and estimated blood loss were not reported in either trial. No trial reported neonatal infection but did report neonatal temperature less than 36.2°C at birth (9% versus 9%; RR 0.98, 95% CI 0.30 to 3.20; 1 trial; 109 infants; very low‐quality evidence), greater than 37.5°C at birth (15% versus 6%; RR 2.62, 95% CI 0.73 to 9.35; 1 trial; 109 infants; very low‐quality evidence), and fever reported in first week (2% versus 5%; RR 0.53, 95% CI 0.10 to 2.82; 1 trial; 171 infants; very low‐quality evidence), with no clear effect between groups being observed. One perinatal death occurred in the immersion group in one trial (RR 3.00, 95% CI 0.12 to 72.20; 1 trial; 120 infants; very low‐quality evidence). The infant was born to a mother with HIV and the cause of death was deemed to be intrauterine infection.

There is no evidence of increased adverse effects to the baby or woman from either the first or second stage of labour.

Only one trial (200 women) compared early and late entry into the water and there were insufficient data to show any clear differences.

Authors' conclusions

In healthy women at low risk of complications there is moderate to low‐quality evidence that water immersion during the first stage of labour probably has little effect on mode of birth or perineal trauma, but may reduce the use of regional analgesia. The evidence for immersion during the second stage of labour is limited and does not show clear differences on maternal or neonatal outcomes intensive care. There is no evidence of increased adverse effects to the fetus/neonate or woman from labouring or giving birth in water. Available evidence is limited by clinical variability and heterogeneity across trials, and no trial has been conducted in a midwifery‐led setting.

Design: a qualitative study was conducted with 12 participants using three focus group discussions. Data were transcribed verbatim and thematic analysis was used to analyse the data.

Setting: UK midwives were recruited from different geographical areas who worked in community areas, hospital areas and as independent practitioners.

Findings: three themes were identified. Firstly, midwives viewed VBB in dimensions of normality, perceiving it to be an unusual norm on one hand while also acknowledging potential problems. Secondly, midwives expressed varied feelings of preparedness; the majority feeling inexperienced and under-prepared with VBB, yet more confident when supported by other colleagues. Lastly, midwives described restrictions on women's choice of VBB; perceiving other practitioners as limiting women's choices through coercion, yet providing a balanced choice themselves.

Conclusions: there should be an opportunity for midwives to be mentored by a more experienced practitioner in VBB. Practice areas should develop a guideline for VBB which acknowledges the role of the midwife in facilitating normal breech birth. Balanced written and verbal information on VBB may further assist decision making for women considering a VBB. Education in VBB should focus on learning what is normal for VBB and must emphasise the importance of teamwork and understanding roles within multidisciplinary teams.

Aim. To integrate the findings of the current literature on the phenomenon of freebirthing, asking the question: ‘Why do some women choose to freebirth?’

Design. A metasynthesis was carried out based upon Noblit and Hare’s (1988) meta-ethnography. Searches were carried out in March 2013 and updated in March 2014 using 15 key databases. Inclusion criteria were applied: primary qualitative work, in English, focusing upon women who had freebirthed intentionally. A quality appraisal was carried out. This paper reports the findings from international studies, as there were no studies based on a UK population.

Findings and key conclusions. Four studies were found that incorporated data collected from 272 women. The studies identified were based in the US (n=3) and in Australia (n=1). Four key themes were generated: rejection of the medical and midwifery models of birth; faith in the birth process; autonomy; and agency. There was a prevailing sense of opting to freebirth in order to retain choice, control and autonomy over their bodies during the birth process.

Implications for practice. For some, within their particular context of maternity provision, the biomedical model of childbirth is clearly not acceptable, therefore, it is important practitioners identify and address women’s bio-psychosocial needs. Even the midwifery model of childbirth is apparently not satisfactory, suggesting the gulf between the midwifery philosophy of care and that which is currently practised needs attention. For some women, a previous negative experience with maternity care provision motivated their decision to freebirth. It is, therefore, important that maternity service providers improve the quality of care provision so women feel dignified, supported, and are participatory in the care that they receive. A UK-based study is being undertaken in order to establish the motivations of women who choose to freebirth in the UK.

Background

For women at low risk of childbirth complications, water immersion during labour is a care option in many high income countries. Our aims were (a) to describe maternal characteristics, intrapartum events, interventions, maternal and neonatal outcomes for all women who used a birthing pool during labour who either had a waterbirth or left the pool and had a landbirth, and for the subgroup of women who had a waterbirth in 19 obstetric units, and (b) to compare maternal characteristics, intrapartum events, interventions, and maternal and neonatal outcomes for women who used a birthing pool with a control group of women who did not use a birthing pool for whom we prospectively collected data in a single centre.

Methods

Prospective observational study in 19 Italian obstetric units 2002-2005. Participants were: (a) 2,505 women in labour using a birthing pool in 19 obstetric units; and (b) 114 women in labour using a birthing pool and 459 women who did not use a birthing pool in one obstetric unit. Descriptive statistics were calculated for the sample as a whole and, separately, for those women who gave birth in water. Categorical data were compared using Chi square statistics and continuous data by T-tests.

Results

Overall, 95.6% of women using a birthing pool had a spontaneous vertex delivery, 63.9% of which occurred in water. Half of nulliparas and three quarters of multiparas delivered in water. Adverse maternal and neonatal outcomes were rare. There were two cases of umbilical cord snap with waterbirth. Compared with controls, significantly more women who used a birthing pool adopted an upright birth position, had hands off delivery technique, and a physiological third stage. Significantly fewer nulliparas had an episiotomy, and more had a second degree perineal tear, with no evidence of a difference for extensive perineal tears.

Conclusions

Birthing pool use was associated with spontaneous vaginal birth. The increase in second degree tears was balanced by fewer episiotomies. Undue umbilical cord traction should be avoided during waterbirth.

Design: cross sectional survey of a consecutive sample of 500 pregnant women attending their first antenatal appointment at approximately 10–11 weeks gestation.

Setting: two antenatal clinics in the South West of England.

Findings: of the 409 women respondents, we found a quarter of women reported drinking alcohol despite being aware they are pregnant. Between two to three in every 100 women reported drinking six or more units on a single occasion (heavy episodic or ‘binge’ drinking) at least monthly or weekly in the past three months. A similar proportion reported exceeding the recommended drinking limits of one to two units, once or twice a week. The majority of heavy episodic drinkers were otherwise low risk drinkers. 5.4% of respondents had an AUDIT-C score of 3 or more, and 22.2% a T-ACE score of 2 or more, indicating risk drinking in the peri-conception period. Drinking pre-conception and/or during the first trimester was more likely if women were multiparous and of white ethnicity.

Key conclusions: in this study pregnant women attending an antenatal appointment were willing to complete brief alcohol screening questionnaires. A minority of women reported drinking pre-conception and/or during the first trimester with a small percentage drinking at levels potentially harmful to the fetus.

Implications for practice: use of these questionnaires would help midwives gather information about alcohol use to help identify women drinking at levels in excess of recommended limits in order that appropriate advice and support be offered.

Background

Our aim was to describe the range of perineal trauma in women with a singleton vaginal birth and estimate the effect of maternal and obstetric characteristics on the incidence of perineal tears.

Methods

We conducted a prospective observational study on all women with a planned singleton vaginal delivery between May and September 2006 in one obstetric unit, three freestanding midwifery-led units and home settings in South East England. Data on maternal and obstetric characteristics were collected prospectively and analysed using univariable and multivariable logistic regression. The outcome measures were incidence of perineal trauma, type of perineal trauma and whether it was sutured or not.

Results

The proportion of women with an intact perineum at delivery was 9.6% (125/1,302) in nulliparae, and 31.2% (453/1,452) in multiparae, with a higher incidence in the community (freestanding midwifery-led units and home settings). Multivariable analysis showed multiparity (OR 0.52; 95% CI: 0.30–0.90) was associated with reduced odds of obstetric anal sphincter injuries (OASIS), whilst forceps (OR 4.43; 95% CI: 2.02–9.71), longer duration of second stage of labour (OR 1.49; 95% CI: 1.13–1.98), and heavier birthweight (OR 1.001; 95% CI: 1.001–1.001), were associated with increased odds. Adjusted ORs for spontaneous perineal truama were: multiparity (OR 0.42; 95% CI: 0.32–0.56); hospital delivery (OR 1.48; 95% CI: 1.01–2.17); forceps delivery (OR 2.61; 95% CI: 1.22–5.56); longer duration of second stage labour (OR 1.45; 95% CI: 1.28–1.63); and heavier birthweight (OR 1.001; 95% CI: 1.000–1.001).

Conclusions

This large prospective study found no evidence for an association between many factors related to midwifery practice such as use of a birthing pool, digital perineal stretching in the second stage, hands off delivery technique, or maternal birth position with incidence of OASIS or spontaneous perineal trauma. We also found a low overall incidence of OASIS, and fewer second degree tears were sutured in the community than in the hospital settings. This study confirms previous findings of overall high incidence of perineal trauma following vaginal delivery, and a strong association between forceps delivery and perineal trauma.

Background: Birthing pools are integrated into maternity care in the UnitedKingdom and are a popular care option for women in midwifery-led units and at home. Theobjective of this study was to describe and compare maternal characteristics, intrapartumevents, interventions, and maternal and neonatal outcomes by planned place of birth forwomen who used a birthing pool. Methods: A total of 8,924 women at low risk of childbirthcomplications were recruited from care settings in England, Scotland, and Northern Ireland.Descriptive analysis was performed. Results: Overall, 7,915 (88.9%) women had aspontaneous birth (5,192, 58.3% water births), of whom 4,953 (55.5%) were nulliparas.Fewer nulliparas whose planned place of birth was the community (freestanding midwiferyunit or home) had labor augmentation by artificial membrane rupture (149, 11.3% [95% CI:9.6-13.1]), compared with an alongside midwifery unit (271, 22.7% [95% CI: 20.3-25.2]),or obstetric unit (639, 26.3% [95% CI: 24.5-28.1]). Results were similar for epiduralanalgesia and episiotomy. More community nulliparas had spontaneous birth (1,172, 88.9%[95% CI: 87.1-90.6]), compared with birth in an alongside midwifery unit (942, 79% [95%CI: 76.6-81.3]) and obstetric unit (1,923, 79.2% [95% CI: 77.5-80.8]); and fewer requiredhospital transfer (265, 20% [95% CI: 17-22.2]) compared with those in an alongsidemidwifery unit (370, 31% [95% CI: 28.3-33.7]). Results for multiparas and newborns weresimilar across care settings. Twenty babies had an umbilical cord snap, 18 (90%) of whichoccurred during water birth. Conclusions: Birthing pool use was associated with a highfrequency of spontaneous birth, particularly among nulliparas. Findings revealed differencesin midwifery practice between obstetric units, alongside midwifery units, and the community,which may affect outcomes, particularly for nulliparas. No evidence was found for adifference across care settings in interventions or outcomes in multiparas or in outcomes fornewborns. During water birth, it is important to prevent undue traction on the cord as thebaby is guided to the surface.

Aims Although prenatal screening for problem drinking during pregnancy has been recommended, guidance on screening instruments is lacking. We investigated the sensitivity, specificity and predictive value of brief alcohol screening questionnaires to identify problem drinking in pregnant women. Methods Electronic databases from their inception to June 2008 were searched, as well as reference lists of eligible papers and related review papers. We sought cohort or cross-sectional studies that compared one or more brief alcohol screening questionnaire(s) with reference criteria obtained using structured interviews to detect 'at-risk' drinking, alcohol abuse or dependency in pregnant women receiving prenatal care. Results Five studies (6724 participants) were included. In total, seven instruments were evaluated: TWEAK (Tolerance, Worried, Eye-opener, Amnesia, Kut down), T-ACE [Take (number of drinks), Annoyed, Cut down, Eye-opener], CAGE (Cut down, Annoyed, Guilt, Eye-opener], NET (Normal drinker, Eye-opener, Tolerance), AUDIT (Alcohol Use Disorder Identification Test), AUDIT-C (AUDIT-consumption) and SMAST (Short Michigan Alcohol Screening Test). Study quality was generally good, but lack of blinding was a common weakness. For risk drinking sensitivity was highest for T-ACE (69-88%), TWEAK (71-91%) and AUDIT-C (95%), with high specificity (71-89%, 73-83% and 85%, respectively). CAGE and SMAST performed poorly. Sensitivity of AUDIT-C at score >= 3 was high for past year alcohol dependence (100%) or alcohol use disorder (96%) with moderate specificity (71% each). For life-time alcohol dependency the AUDIT at score >= 8 performed poorly. Conclusion T-ACE, TWEAK and AUDIT-C show promise for screening for risk drinking, and AUDIT-C may also be useful for identifying alcohol dependency or abuse. However, their performance as stand-alone tools is uncertain, and further evaluation of questionnaires for prenatal alcohol use is warranted.

Background Parenteral opioids are used for pain relief in labour in many countries throughout the world. Objectives To assess the acceptability, effectiveness and safety of different types, doses and modes of administration of parenteral opioids given to women in labour. Search strategy We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (January 2010) and reference lists of retrieved studies. Selection criteria We included randomised controlled trials examining the use of intramuscular or intravenous opioids (including patient controlled analgesia) for women in labour. We looked at studies comparing an opioid with placebo or another opioid. Data collection and analysis At least two review authors independently assessed study eligibility, collected data and assessed risk of bias. Main results We included 54 studies involving more than 7000 women that compared an opioid with placebo or another opioid administered intramuscularly or intravenously. The 54 studies reported on 27 different comparisons, and for many outcomes only one study contributed data. Overall the evidence was of poor quality regarding the analgesic effect of opioids, satisfaction with analgesia, adverse effects and harm to women and babies. There were few statistically significant results. Many of the studies had small sample sizes, and low statistical power. Overall, findings indicated that parenteral opioids provided some pain relief and moderate satisfaction with analgesia in labour, although up to two-thirds of women who received opioids reported moderate or severe pain and/or poor or moderate pain relief one or two hours after administration. Opioid drugs were associated with maternal nausea, vomiting and drowsiness, although different opioid drugs were associated with different adverse effects. There was no clear evidence of adverse effects of opioids on the newborn. We did not have sufficient evidence to assess which opioid drug provided the best pain relief with the least adverse effects. Authors' conclusions Parenteral opioids provide some relief from pain in labour but are associated with adverse effects. Maternal satisfaction with opioid analgesia was largely unreported but appeared moderate at best. We did not examine the effectiveness and safety of parenteral opioids compared with other methods of pain relief in labour and this review needs to be examined alongside related Cochrane reviews. More research is needed to determine which analgesic intervention is most effective, and provides greatest satisfaction to women with acceptable adverse events for mothers and their newborns.

Background Enthusiasts suggest that labouring in water and waterbirth increase maternal relaxation, reduce analgesia requirements and promote a midwifery model of care. Sceptics cite the possibility of neonatal water inhalation and maternal/neonatal infection. Objectives To assess the evidence from randomised controlled trials about immersion in water during labour and waterbirth on maternal, fetal, neonatal and caregiver outcomes. Search strategy We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (October 2008). Selection criteria Randomised controlled trials comparing any bath tub/pool with no immersion during labour and/or birth. Data collection and analysis We assessed trial eligibility and quality and extracted data independently. One review author entered data and another checked for accuracy. Main results This review includes 11 trials (3146 women); eight related to the first stage of labour, one to the first and second stages, one to early versus late immersion in the first stage of labour, and another to the second stage. We identified no trials evaluating different baths/pools, or the management of third stage of labour. Results for the first stage of labour showed there was a significant reduction in the epidural/spinal/paracervical analgesia/anaesthesia rate amongst women allocated to water immersion compared to controls (478/1254 versus 529/1245; odds ratio (OR) 0.82, 95% confidence interval (CI) 0.70 to 0.98, six trials). There was no difference in assisted vaginal deliveries (OR 0.84, 95% CI 0.66 to 1.06, seven trials), caesarean sections (OR 1.23, 95% CI 0.86 to 1.75, eight trials), perineal trauma or maternal infection. There were no differences for Apgar score less than seven at five minutes (OR 1.59, 95% CI 0.63 to 4.01, five trials), neonatal unit admissions (OR 1.06, 95% CI 0.70 to 1.62, three trials), or neonatal infection rates (OR 2.01, 95% CI 0.50 to 8.07, five trials). A lack of data for some comparisons prevented robust conclusions. Further research is needed. Authors' conclusions Evidence suggests that water immersion during the first stage of labour reduces the use of epidural/spinal analgesia. There is limited information for other outcomes related to water use during the first and second stages of labour, due to intervention and outcome variability. There is no evidence of increased adverse effects to the fetus/neonate or woman from labouring in water or waterbirth. The fact that use of water immersion in labour and birth is now a widely available care option for women threatens the feasibility of a large, multicentre randomised controlled trial.