Non-invasive analgesic techniques – immersion in water in the first stage of labour

Bibliographic reference Study type Evidence level Number of women Women’s characteristics Intervention Comparison Length of follow-up Outcome measures Effect size Source of funding Additional comments
Cluett 2004128SR18 RCT (2939 women).Pregnant womenThe use of any kind of bath tub/pool that allows immersion compared with no immersion during the first stage of labour
The use of any kind of bath tub/pool that allows immersion compared with no immersion during the second stage of labour
Comparison of different kinds and sizes of baths, i.e. whirlpool versus bath tub/pool
Comparison of different additives
Comparisons of early versus late immersion in water during labour
N/AMaternal outcomes
Fetal outcomes
Neonatal outcomes
Caregiver outcomes
Immersion versus no immersion in the first stage of labour

Maternal outcomes
Four trials provided data on epidural/spinal analgesia/anaesthesia and there was a statistically significant reduction in the incidence of epidural/spinal/paracervical analgesia/anaesthesia amongst women allocated to immersion in water during the first stage of labour compared to those not allocated to water immersion (471/1196 versus 521/1210; odds ratio (OR) 0.84, 95% confidence interval (CI) 0.71 to 0.99). Of these trials reported that 183/393 (46%) of the women allocate to water immersion did not actually use water. However, they analysed the data on an intention to treat basis, and do not provide subgroup analysis by actual intervention received. Four trials provided data on duration of the first and second stages of labour, and there were no statistically significant differences. Six trials reported on the incidence of operative delivery. Overall there was no statistically significant difference; assisted vaginal delivery incidence immersion compared to non-immersion (OR 0.83, 95% CI 0.66 to 1.05) and caesarean section rate immersion compared to non-immersion (OR 1.33, 95% CI 0.92 to 1.91). There were no statistically significant differences between the benefits and risks associated with the use of water immersion during labour on parameters such as perineal trauma: episiotomy (171/550 versus 186/554; OR 0.89, 95%CI 0.68 to 1.15 ), second degree tears (95/550 versus 104/554; OR 0.90, 95% CI 0.66 to 1.23) and third/fourth degree tears (39/1162 versus 29/1179; OR 1.38, 95% CI 0.85 to 2.24).

One trial reported maternal pain and women who used water immersion during the first stage of labour reported statistically significant less pain (using ordinal descriptors) than those not labouring in water (40/59 versus 55/61; OR 0.23, 95% CI 0.08 to 0.63).

One trial confirmed the biophysiological effect of immersion in water on the effect of blood pressure changes; systolic (mean 120.3 mmHg versus 127.5 mmHg; weighted mean difference (WMD) −7.20, 95% CI −13.12 to −1.28), diastolic (mean 62.8 mmHg versus 73 mmHg; WMD −10.20, 95% CI −13.70 to −6.70); and mean arterial pressure (mean 83.7 versus 127.5; WMD −10.50, 95% CI −14.68 to −6.32) were statistically significantly reduced in the immersion group.

Neonatal outcomes
Five trials reported on APGAR scores at five minutes and there was no significant difference in the incidence of a score of less than seven at five minutes between groups, (OR 1.59, 95% CI 0.63 to 4.01). Two trials reported admissions to the neonatal intensive care unit and found no difference in admission rates between groups, (OR 1.05, 95% CI 0.68 to 1.61). Infection rates were very low (6/629 versus 3/633) and reported in four trials (OR 2.01, 95% CI 0.50 to 8.07;.

Caregiver outcomes
No trial describes any injuries or satisfaction outcomes for care givers.

Immersion versus no immersion in the second stage of labour
The one trial evaluating immersion during the second stage of labour demonstrated a significant difference in the pushing experience of the women. Fewer women in the immersion group felt that they did not cope satisfactorily with their pushing efforts (3/60 versus 12/57). There were no significant differences in any of the outcomes measured such as trauma to the perineum, episiotomy (3/60 versus 4/59) and second degree tears (13/60 versus 11/59), admission to neonatal intensive care unit (3/60 versus 5/60) and the neonate’s temperature at birth more than 37.5° Celsius (8/55 versus 3/54).

Early versus late immersion
One trial compared early versus late immersion during the first stage of labour and found significantly higher epidural analgesia rates in the early group (42/100 versus 19/100; OR 3.09, 95% CI 1.63 to 5.84) and an increased use of augmentation of labour (57/100 versus 30/100; OR 3.09, 95% CI 1.73 to 5.5.4).
No sources of support supplied
Cluett 2004129RCT1−N=99Nulliparous women with dystocia (cervical dilation rate < 1 cm/hour in active labour) at low risk of complications.Interventions: Immersion in water in birth poolStandard augmentation for dystocia (amniotomy and intravenous oxytocin).PostnatalMain outcome measures: Primary: epidural analgesia and operative delivery rates.
Secondary: augmentation rates with amniotomy and oxytocin, length of labour, maternal and neonatal morbidity including infections, maternal pain score, and maternal satisfaction with care.
Results:
epidural analgesia RR 0.71 (95% confidence interval 0.49 to 1.01)
operative delivery RR 0.98 (0.65 to 1.47), augmentation RR, 0.74 (0.59 to 0.88) any form of obstetric intervention (amniotomy, oxytocin, epidural, or operative delivery) RR 0.81(0.67 to 0.92), Babies admitted to the neonatal unit 6 v 0, P = 0.013
Apgar score, infection rates, or umbilical cord pH:
Not significant
Not stated

From: Evidence tables

Cover of Intrapartum Care
Intrapartum Care: Care of Healthy Women and Their Babies During Childbirth.
NICE Clinical Guidelines, No. 55.
National Collaborating Centre for Women's and Children's Health (UK).
London: RCOG Press; 2007 Sep.
Copyright © 2007, National Collaborating Centre for Women’s and Children’s Health.

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