Introduction
In 2018 the World Health Organisation (1) published
recommendations for intrapartum care, with an intentional focus on a
positive childbirth experience as a significant end point for women
undergoing labour and birth. Several studies suggest that warm water
immersion (WWI) and waterbirth result in increased maternal satisfaction
with the birth experience (2-4), likely due to an
increased sense of control (2, 5, 6) and improved pain
management (7).
The practice is supported by several studies demonstrating reassuring
clinical outcomes and increasing maternal preference for waterbirth(4). Two recent systematic reviews(6, 8), demonstrate no increased risk of harm to the
mother or neonate; rather evidence suggests afforded benefit including a
reduction in the use of regional anaesthesia and length of labour, with
no significant differences in neonatal morbidity (6,
8).
Whilst WWI has been both embraced and encouraged by midwives;
obstetricians remain mostly reluctant to ‘take the plunge’ and support
this practice, citing concerns over safety and a paucity of evidence.
The American College of Obstetricians and Gynaecologists (ACOG) still
recommends that birth occurs on land (9). Qualitative
studies report a lack of support for WWI from obstetricians, most
notably where women have additional risk factors (10,
11). This was particularly prevalent on obstetric units whereby senior
staff did not appreciate the benefits of WWI and were seen to promote a
medicalised approach to labour and birth (11). The
Royal Australian and New Zealand College of Obstetricians and
Gynaecologists (RANZCOG) acknowledges this lack of support for
waterbirth amongst the medical community; suggesting that more research
is required in the area (10).
As a cohort, pregnant women are increasingly medically complex(12), induction rates are rising(13) and consequently the number of women requiring
Continuous Electronic Fetal Monitoring (CEFM) is high. Whilst there is
sound evidence to support WWI and waterbirth in low-risk women(6), there is an absence of literature to support use
in those with moderate obstetric risk-factors, who may be recommended to
use CEFM during labour.
In our unit in Queensland, Australia, birthing pools were installed in
12 of 15 birth suites, and were equipped with wireless, waterproof CEFM,
giving women unprecedented access to WWI and waterbirth. This study aims
to investigate the maternal and fetal outcomes following WWI and/or
waterbirth compared with land birth, including for those women with
moderate obstetric risk factors, for example, those intending a vaginal
birth after caesarean (VBAC) or requiring oxytocin administration.