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.