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Running head: AN INTEGRATIVE REVIEW 1

An Integrative Review

Lindsey A. Brookmire

NUR 4122: Nursing Research

November 11, 2016

HONOR CODE- I pledge


AN INTEGRATIVE REVIEW 2

Abstract

The purpose of this integrative review was to appraise the literature pertaining to the effects of

water birth on maternal and neonatal outcomes. Water birth has raised concerns regarding safety

to the neonate and outcomes of the mother. Studies have reported that water birth promotes

relaxation and pain relief to laboring women. The literature gathered was conducted using online

databases: EBSCO Discovery Services and PubMed. The search generated 40 research articles,

five of which were pulled to conduct the review. Findings displayed an overall decrease in pain

and adverse events experienced by women who delivered in water. The results also presented as

a safe method of delivery to the neonate. Limitations to this review included a lack of pertinent

literature published and the researchers inexperience in this field. Continued research needs to

be conducted to gain a stronger understanding of water birth and recommendations for future

research suggest conducting qualitative studies.


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An Integrative Review

The purpose of this paper is to provide an integrative review of maternal and neonatal

complications associated with water birth. Traditional birthing can be a very painful experience

for the mother, putting stress on both her and her baby. Compared to a traditional birth, Gayiti,

Li, Zulifeiya and Zhao (2015) state that water delivery is a delivery mode that can decrease the

pain associated with delivery, shorten the duration of the delivery, and be beneficial for

newborns adaptation to the new environment. This non-medical method is becoming more

popular among women as the evidence reports a decrease in birthing pain and promotes

relaxation. Likewise, Swain (2013) explains that water birth reduces perineal tearing and allows

the mother to freely assume comfortable positions for pushing. The aim of this integrative review

was to look into greater detail on literature relating to the researchers PICO question: for women

in labor, does water birth reduce the risk of maternal and neonatal complications during delivery

compared to traditional birth? With limited research available on this subject, a thorough review

of the literature is necessary to collect information pertinent to the study topic.

Design and Search Methods

This integrative review consists of five research articles pertaining to the topic of interest.

Databases accessed through the college were used to explore different studies and find

information relevant towards the researchers PICO question. Search engines were manipulated;

EBSCO Discovery Services for four articles and PubMed for one article. Key words used to

explore different articles included, birthing pool, water birth, neonatal outcomes, maternal

outcomes, birth position, and analgesia. PubMed yielded 12 and EBSCO Discovery Services

yielded 28. To capture articles with relevant results, the search was limited to publication from

2011-2016, peer reviewed journal articles of English language, with the subject matter of
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pregnancy. Journal articles that did not meet the criteria were excluded from the integrative

review. The screening produced five articles, all of which were quantitative.

Findings and Results

The quantitative studies used in this integrative review discuss maternal or neonatal

experiences related to water birth. Each article has outcomes relating to water births that are

beneficial to answering the original PICO question. Four of the five studies contain research on

the maternal effects of water birth while all articles discuss its effects on the neonate. A summary

of each research article is presented in Table 1. The following categories outline the findings

gathered from this review: maternal outcomes and neonatal outcomes.

Maternal Outcomes

Four of the quantitative articles researched the outcomes women experienced during the

water birthing process. In a retrospective cohort study conducted by Bovbjerg, Cheyney, and

Everson (2016) data was collected from the Midwives Alliance of North American Statistics

Project from 2004-2009 to compare the outcomes of women who followed through with a water

birth, intended on a water birth but did not deliver in water, and women who had a non-water

birth. The purpose of the study was to report outcomes from a large sample of midwife-led births

both at home and in birthing centers. The sample consisted of 18,343 pregnancies and 18,397

newborns.

The studys data was analyzed using SPSS and S-Plus Version 8.1. Logistic regression

analyzed outcomes such as postpartum transfer, postpartum reproductive tract infection, maternal

hospitalization in the first six weeks, and dichotomized trauma. The researchers found that, in

comparison to non-water births, water births had a 35% reduction in postpartum transfers, a 28%

reduction in the odds of being hospitalized in the first 6 weeks, and an increase of 11% in
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occurrence of genital tract trauma. Water birth had no association with uterine or perineal

infections. The researchers concluded that water birth is reasonably safe for mothers with low-

risk pregnancies.

Burns, Boulton, Cluett, Cornelius and Smith (2012) conducted a prospective

observational study to compare maternal outcomes of water birthing in different care settings

such as community, obstetric units, and alongside midwifery units. The purpose of this study was

to gather data from a large sample of women who used a birthing pool under the care of

midwives form the National Health Service. This quantitative study recruited a sample of 8,924

women through midwives from care settings in Ireland, England, and Scotland. Midwives

recorded laboring women and birth information on a standardized form. One midwife from each

unit was nominated to co-coordinate data collection, collect and check forms for completion, and

enter the data using Excel. Every 6 months, the nominated midwife was required to send data to

the primary investigator so datasets could be checked and missing data could be noted. The

maternal variables incorporated into this study included type of delivery, active or physiologic

third stage, length of labor, perineal trauma, hospital transfer, major or minor postpartum

hemorrhage, manual removal of placenta, infection, readmission, pyrexia, and death.

Data was analyzed using SPSS, central tendencies, dispersion, Chi-squared, and t-tests.

The researchers found that of the 5,192 women who gave birth in water, only 9% had an

episiotomy, 2% had a third degree tear, and one-third had an intact perineum. They also found

that women who labored and delivered in the community setting, a freestanding midwifery unit

or home birth, had fewer augmentations, epidurals, operative vaginal deliveries, cesarean

sections, episiotomies, and minor postpartum hemorrhage than obstetric units and alongside

midwifery units.
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Dahlen, Dowling, Tracy, Schmied, & Tracy (2013) conducted a descriptive cross-

sectional study to determine the rates of perineal trauma and postpartum hemorrhage amongst

low-risk women who gave birth via water compared to 6 birthing positions outside of water.

They also studied the relationship of these outcomes in relation to the care received: midwife led

care or obstetrician led care. This quantitative study collected data from handwritten records

midwives used for 6,144 individual births from January 1996 to April 2008. The data gathered

included descriptions of birthing positions, parity, lengths of different stages of labor, blood loss,

accoucher, trauma to the perineum, suturing requirements, shoulder dystocia, physiologic or

active third stage management, oxytocin use, and analgesia.

All maternal data was entered into and analyzed with SPSS. Chi square and logistic

regressions were used in examining differences between the birthing positions and two logistical

regression models were developed for perineal trauma and postpartum hemorrhage. Results

indicated that water birth had better perineal outcomes with lower rates of hemorrhaging. In

relation to the water birth and the land positions of all fours or kneeling, semi-recumbent, lateral,

standing, birthing stool, and squatting, birth on a stool led to the highest rate or perineal trauma

and postpartum hemorrhage. The researchers also found that women cared for by obstetricians

had a higher rate of perineal trauma than women cared for by midwives.

A quantitative study conducted by Mollamahmutolu et al. (2012) researched the effects

of water immersion during labor and delivery on the maternal, fetal, and neonate well-being to

compare the safety and outcomes of conventional vaginal deliveries and deliveries with epidural

analgesia. Women had to be 37-42 weeks gestational age, no history of cesarean sections,

membranes intact, no placental abruption/previa, no fetal malpresentation, normal sized fetus,

and normal fetal well-being results. The sample consisted of 610 pregnant women admitted to a
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specific hospital between June 2007 and September 2008. The study consisted of a control and

two study groups: the control group as conventional vaginal deliveries, a study group with

women electing for water birth, and a study group with vaginal deliveries using epidural

analgesia. A questionnaire collected demographic data, length of each labor stage, requirements

for induction and episiotomy, perineal trauma, and the visual analog scale (VAS).

Data was evaluated using SPSS and groups were compared by the Chi-square test.

Oneway ANOVE, Bonferroni tests, and Kruskall-Wallis oneway ANOVA were used to analyze

continuous variables with normal and non-normal distribution. Mollamahmutolu et al. (2012)

results stated that the first stage of labor was shortest in the conventional vaginal delivery group

and the second and third stage of labor was shortest in the water birth group. The third stage

consists of delivery of the placenta; therefore, a shorter period minimizes blood loss. The water

birth group had a significant reduction in inductions and episiotomy requirements, and contained

the lowest VAS scores, even in relation to women who received an epidural. Women who birthed

in water also had lower rates of Apgar scores <7 and blood pressure readings, but these results

were insignificant. The water birth group did however have an increased rate of perineal

lacerations, but these lacerations were less severe than those experienced by the conventional

vaginal delivery group.

Neonatal Outcomes

Demirel et al. (2013) conducted a study with the aim to determine fetal outcomes of

water birth. This retrospective study consisted of 191 infants born in water from January 2005 to

May 2010 at a tertiary center. The pregnant women had to be considered low-risk in order to

follow through with a water delivery. Data was recorded retrospectively from patient files and

included clinical features of patients, hospitalization information, nutritional status, and birthing
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complications such as trauma, infection, and NICU attendance. Statistical analysis was

conducted through SPSS and expressed as a mean score incorporating standard deviation.

Of the 191 neonates, only 3 (1.6%) experienced a birth trauma: brachial nerve paralysis,

cord rupture, and cephalic hematoma. An additional 6 (3%) neonates were admitted to the NICU

for respiratory tract problems or neonatal pneumonia. No patients needed an extensive

hospitalization from these complications and all other neonates were evaluated as healthy.

The retrospective study discussed prior by Bovbjerg et al. (2016) also incorporated

outcomes of the neonate when delivered in water into their study. Continuing with SPSS, S-Plus,

and logistic regression to analyze the data gathered from the Midwives Alliance of North

America Statistics Project from 2004-2009, the researches focused on neonatal Apgar scores,

transfer to the hospital, admission to hospital during first 6 weeks, and early or late neonate

deaths. After analysis of the neonatal data, the authors found that water births fared better than

neonates born outside of water. Water birth neonates had fewer negative outcomes all around

than non-water births.

Similarly, Burns et al. (2012) included neonatal outcomes related to water birth in their

prospective study as well. Midwives gathered data regarding neonatal Apgar scores at 1, 5, and

10 minutes, birthweights, resuscitation occurrences, respiratory difficulty requiring intervention,

cord snap, shoulder dystocia, infection, readmission, NICU admission, and death. The

researchers were able to conclude that serious neonatal outcomes were uncommon with the water

birth delivery method. Only 1.6% were admitted to the NICU, 1.2% needed resuscitation, 0.73%

had respiratory difficulty, 0.22% with umbilical cord snaps, and 0.39% developed pyrexia. None

of these neonatal outcomes were serious enough to have an extended hospital stay.
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The cross-sectional study mentioned earlier in this integrative review by Dahlen et al.

(2013) researched neonatal 5-minute Apgar outcomes in addition to the maternal outcomes. A

model using logistic regression was developed to analyze Apgar scores for babies delivered in

water or in one of the six positions on land. They also looked at the Apgar scores in relation to

midwifery led care or obstetrician led care. The researchers concluded that there were no

differences in Apgar scores at 5 minutes between water birth and other birthing positions except

for the semi-recumbent position, which had poorer outcomes. Also, women that were cared for

by obstetricians as opposed to midwives had higher rates of babies born with Apgar scores < 7 at

5 minutes.

Mollamahmutolu et al. (2012) included in their research outcomes experienced by the

neonates in relation to water births and conventional vaginal deliveries. The questionnaire

collected data in regards to Apgar scores and NICU requirements. The researchers concluded that

there were no differences in NICU admissions, neonatal infection rates, adverse perinatal

outcomes, or deaths between the groups studied.

Discussion and Implications

Maternal Outcomes

Maternal outcomes of women who gave birth in water were similar through the articles

used in this review. Given that the results were consistent throughout the literature, the

researchers PICO question was adequately addressed. The PICO question wanted to determine

the outcomes water birth portrays on the laboring woman, so the effects can be compared with

that of traditional delivery. The evidence supports that water birth had a decrease in

complications across the board except for the two studies that found increased rates of perineal

trauma. Common variables shared across the studies included postpartum hemorrhaging, pain,
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labor length, hospital transfers, infection, readmission, and postpartum transfer to a hospital.

Every study only involved women with low-risk pregnancies and data was evaluated using

SPSS. Recommendations for future research include incorporation of qualitative studies which

are not known to be conducted or currently published. A greater understanding of womens

perspectives and experiences after a water delivery will help expand research in this area.

Neonatal Outcomes

The studies researched in this review show similarity in outcomes neonates experience

from water birth. All articles data was evaluated using SPSS. While there were occasional

birthing complications, none were statistically significant. Two articles discussed that their

neonates who experienced birth trauma or complications did not need to extend their

hospitalization time as a resulting factor. Common variables measured for adverse neonatal

outcomes include Apgar scores, respiratory difficulty, infection, and admission to NICU. The

information gathered from this review supports the researchers PICO question which sought to

determine the safety of water birth on the neonate compared to a traditional delivery. The

evidence supports that participants had no significant harm inflicted from birthing in water.

Limitations and Conclusion

Limitations of the integrative review may impact the researchers findings and review.

This topic has limited information and literature which makes certain studies biased to a specific

population. A major limitation that needs to be addressed is the integrative reviewers

inexperience working in this field. All information had to be gathered by published research and

there was no personal experience to refer to. A knowledge deficit in this field impacts the

researchers ability to fully understand all the material and verbiage unless further investigation
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is conducted. This review was also a class assignment that limited the search to 5 articles

published less than 5 years ago, therefore not an exhaustive review.

The findings and results of this integrative review suggest that water birth is a safe

method of delivery that decreases the risk of harmful maternal outcomes and is safe to the

neonate. The information gathered provides sufficient evidence that health care providers can

incorporate into water birth education and be used to guide future research. Informing women

about the decreased rates of hemorrhaging and degree of perineal lacerations with an overall

improved comfort level can decrease anxiety women experience about the birthing process. To

those unsure of the safety and effects on the neonate, evidence from this review supports that

there is no increase in adverse events; this will be encouraging to women. It is safe to conclude

that for a low risk pregnancy, women could strongly consider water birth as a method for

delivery.
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References

Bovbjerg, M. L., Cheyney, M. and Everson, C. (2016), Maternal and newborn outcomes

following waterbirth: The Midwives Alliance of North America Statistics Project, 2004 to

2009 Cohort. Journal of Midwifery & Women's Health, 61, 1120.

Burns, E. E., Boulton, M. G., Cluett, E., Cornelius, V. R., & Smith, L. A. (2012). Characteristics,

interventions, and outcomes of women who used a birthing pool: A prospective

observational study. Birth: Issues in Perinatal Care, 39(3), 192-202. doi:10.1111/j.1523-

536X.2012.00548.x

Dahlen, H. G., Dowling, H., Tracy, M., Schmied, V., & Tracy, S. (2013). Maternal and perinatal

outcomes amongst low risk women giving birth in water compared to six birth positions

on land. A descriptive cross sectional study in a birth centre over 12 years. Midwifery,

29(7), 759-764. doi:10.1016/j.midw.2012.07.002

Demirel, G., Moraloglu, O., Celik, I. H., Erdeve, O., Mollamahmutoglu, L., Oguz, S. S., & ...

Dilmen, U. (2013). The effects of water birth on neonatal outcomes: A five-year result of

a referral tertiary centre. European Review for Medical and Pharmacological Sciences,

17(10), 1395-1398.

Gayiti, M., Li, X., Zulifeiya, A. K., Huan, Y., & Zhao, T. (2015). Comparison of the effects of

water and traditional delivery on birthing women and newborns. European Review for

Medical and Pharmacological Sciences, 19(9), 1554-1558

Mollamahmutolu, L., Moralolu, ., zyer, ., Su, F. A., Karayaln, R., Hanerliolu, N.,

& ... Dilmen, U. (2012). The effects of immersion in water on labor, birth and newborn

and comparison with epidural analgesia and conventional vaginal delivery. Journal of

The Turkish-German Gynecological Association, 13(1), 45-49. doi:10.5152/jtgga.2012.03


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Swain, D. (2013). Water Birth is an alternative to air birth- A comprehensive review


article. Asian Journal of Nursing Education & Research, 3(2), 69-78.
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Table 1 Quantitative Article Evaluation

First Author Hannah G. Dahlen (2013), RN, RM, PhD (Associative Professor of Midwifery)
(Year)/Qualifications
Background/Problem Women have the option of water birth & safety concerns are an issue with this method of delivery
Statement Aim: to determine rates of perineal trauma, postpartum hemorrhage, and 5 minute Apgar scores
amongst low-risk women in a birth center who gave birth to in water compared to 6 birthing positions
on land
Conceptual/theoretical No framework was discussed
Framework
Design/Method/Philosophical Quantitative research
Underpinnings Descriptive cross-sectional study
Sample/ Setting/Ethical 6,144 pregnant woman; 819 for waterbirth & 5,220 for land birth using different birthing positions
Considerations The birth center was located in the same building as the Delivery Ward in case if access to medical
intervention is needed
Women needed to be low-risk
Major Variables Studied Parity= primiparous, multiparous
Accoucher= midwife accoucher, obstetrician accoucher
Pain Relief= no pharmacological pain relief, pharmacological pain relief
Water birth & land positions= water, all fours/kneel, semi-recumbent, lateral, standing, stool, squatting
Third stage management= active third stage, physiologic third stage
Postpartum blood loss= 0-499 mL, 500-999 mL, > 1000 mL
Perineal status= intact, first degree, second degree, labial/vaginal tear/graze, third and fourth degree
tears, episiotomy
Apgar score= at 5 minutes
Measurement Tool/Data Collected data from handwritten records midwives used for each birth at the birth center from January
Collection Method 1996 to April 2008
Data included detailed descriptions of birth positions, parity, length of first/second/third stage of labor,
blood loss, accoucher, perineal trauma, sutured or not sutured, shoulder dystocia, physiologic or
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active third stage management, use of oxytocin for third stage and analgesia
Data Analysis All data was entered into and analyzed with SPSS
Descriptive statistics were used for analysis and Chi square and logistic regression were used to
examine differences between birth position groups
3 models using logistic regression were developed for perineal trauma, postpartum hemorrhage, and
Apgar scores and their influencing variables (birth position, birth weight, parity, second stage,
accoucher)
Findings/Discussion Women with babies > 4,000GM , had second stage > 120min, were primiparous or delivered by
obstetrician all had significantly higher rates of major perineal trauma
Compared to waterbirth, birth on stool had higher rate of postpartum hemorrhage
Women with babies > 4,000GM, were primiparous or had major perineal trauma all had significantly
higher rates of postpartum hemorrhage
Women with babies >4,000GM, were primiparous, or had obstetrician had significantly higher rates of
5 minute Apgar scores <7
Water birth had better perineal outcomes and lower rates of postpartum hemorrhage than women who
had birth on a stool
Neonates born in water had improved Apgar scores at 5 minutes compared to women who birthed in
semi-recumbent birth positions
Women cared for by obstetricians compared to midwives had higher rates of perineal trauma and
babies born with Apgars of <7 at 5 minutes
Appraisal/Worth to practice Women who gave birth in water compared to the 6 positions on land had less perineal trauma, lower
rates of postpartum hemorrhage, and fewer Apgar scores <7
Midwifery led care to reduced incidence of major perineal trauma and low Apgar scores with no
difference in postpartum hemorrhage compared to obstetric led care
The study provides great statistics on birthing positions and care providers that nurses can use to
educate women who are/would like to become pregnant
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First Author G. Demirel (2013) Division of Neonatology


(Year)/Qualifications
Background/Problem There is limited information about the effects of water birth on newborns
Statement Aim: detect the fetal outcomes of water birth
Conceptual/theoretical Was not discussed
Framework
Design/Method/Philosophical Quantitative study
Underpinnings Retrospective study of infants born from January 2005 to May 2010 at their tertiary center
Sample/ Setting/Ethical 191 newborns who were born in water
Considerations Pregnant women with > 37 weeks gestation, normal sized fetus, a reactive cardiogram, clear amniotic
fluid, and cephalic presentation who gave birth in water
Approved by the local ethic committee; women interested in water birth signed written consent
Major Variables Studied Neonates delivered in water
Measurement Tool/Data Delivery and hospitalization data of newborns were recorded retrospectively from patient files
Collection Method Demographic and clinical features of patients, hospitalization data, nutritional status, birth
complications (trauma, infection, NICU attendance) were evaluated
Data Analysis SPSS 16 for Windows was used for statistical analysis
Analysis expressed as mean +/- standard deviation; p< 0.05 was considered statistically significant
Findings/Discussion 3 of the 191 (1.6%) neonates experienced birth trauma (brachial nerve paralysis, cord rupture, cephal
hematoma)
6 of the 191(3%) neonates were admitted to the NICU (respiratory tract problems, neonatal
pneumonia)
No patients needed extended hospitalization time resulting from these complications; remainder
evaluated as healthy
Appraisal/Worth to practice This study has demonstrated that water birth for the majority of the patients were safe
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Water birth is an alternative therapy that all women should have the option to pursue if pregnancy is
considered low-risk
The effect of neonate outcomes was acceptable in numbers with no serious, long term complications

First Author Ethel Burns (2012), RM, MSc, Senior Lecturer Midwifery
(Year)/Qualifications
Background/Problem Birthing pools are an option that promotes spontaneous birth with less interventions and is a
Statement nonpharmacological sources for pain relief and facilitate a normal birth
Purpose of the study was to gather prospective observational data from a large sample of women who
used a birthing pool and cared by midwives from the National Health Service
Aim: describe maternal characteristics, interventions, intrapartum events, and outcomes of
neonates/women who used birthing pool during labor; compare maternal characteristics, interventions,
intrapartum events, and maternal/neonate outcomes from those in hospital, midwifery units, and home
settings
Conceptual/theoretical No framework discussed
Framework
Design/Method/Philosophica Quantitative study
l Descriptive analysis
Underpinnings A prospective observational study
Sample/ Setting/Ethical Sample of 8,924 women, low-risk of birthing complications
Considerations Recruited from care settings in Ireland, England, and Scotland
Inclusion criteria: uncomplicated pregnancy, single fetus with cephalic presentation, labor > 37 weeks,
no preexisting disease that could affect labor
Care settings comprised: obstetric units that had midwives, obstetricians, anesthetists, and
pediatricians; midwife units located inside the hospital building; midwife units located away from the
hospital; midwifes that attend home births
Approval to conduct the study was obtained from Oxford Brookes University
Individual consent from women was not required
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Major Variables Studied Intrapartum events and interventions: analgesia, augmentation by artificial rupture of membranes
and/or intravenous infusion of oxytocin, reasons for leaving the birthing pool before delivery, time spent
in the birthing pool
Maternal outcomes: type of delivery, active or physiological third stage, labor length, perineal trauma,
hospital transfer (when and reason), postpartum hemorrhage graded as a minor (500mL-1000mL) and
major (>1000mL), manual remover of placenta, infection, pyrexia, readmission, death
Neonatal outcomes: Apgar scores (at 1, 5, and 10 min), birthweight, resuscitation, respiratory difficulty
requiring treatment, cord snap, shoulder dystocia, infection, readmission, NICU admission, death
Measurement Tool/Data Midwives recorded data on a standardized form as they cared for laboring women and birth
Collection Method A midwife from each unit was nominated to co-coordinate data collection, collecting and checking
forms for completeness, and entered data using Excel
Each units midwifed had to send data every 6 months so the primary investigator could check
datasets and track missing data
Data Analysis SPSS data analysis program; frequencies calculated (number, percent, 95 percent confidence interval)
for categorical data
Measures of central tendencies (mean & median) & dispersion (SD & range) for continuous data
Maternal- Chi-squared for categorical data
Maternal- Independent t test for continuous data
Findings/Discussion Almost 1/3 women had an intact perineum, 9% had an episiotomy, 2% had a third degree tear, 0.9%
with major postpartum hemorrhage
Serious neonate outcomes were uncommon: NICU admission (1.6%), resuscitation (1.2%), respiratory
difficulty (0.73%), umbilical cord snaps (0.22%), pyrexia (0.39%); no extended hospital stay
The community setting had fewer augmentations, epidurals, operative vaginal deliveries, cesarean
sections, episiotomies, and minor postpartum hemorrhage than obstetric units and midwifery units
Appraisal/Worth to practice Birthing pools are associated with a high frequency of spontaneous and normal births
Water birthing differences were found in labor events, interventions, and maternal outcomes across
care settings
Care settings have shown to impact the process of labor and delivery and should be further
researched
The studys data will help nurses and practitioners inform women about using birthing pools and during
labor in the hospital, midwife-led, and community settings
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First Author Marlit L. Bovbjerg (2016)/ PhD, MS


(Year)/Qualifications
Background/Problem Laboring in water may reduce maternal pain and stress on tissues
Statement Neonates may benefit from a water birth by being born into a warm, liquid environment which is similar
to amniotic fluid
American Academy of Pediatrics and American College of Obstetricians and Gynecologists advise
against women laboring in water after completing the first stage of labor
Problem statement: is laboring in water considered safe
Purpose: to report waterbirth outcomes from a large sample of midwife-led births occurring at home &
in birth centers in the US
This retrospective cohort study is one of the first to use/focus on an United States population and is
the largest on this topic to date
Conceptual/theoretical Researchers wanted to compare the effects of waterbirth and nonwaterbirth to determine the safety of
Framework the delivery option
Design/Method/Philosophical Retrospective cohort study
Underpinnings Quantitative study
Directed Acyclic Graph (DAG) methodology was used to determine a complete set of potential
confounders to maximize use of available data while reducing bias; details on DAG for this analysis is
available from authors on request
Sample/ Setting/Ethical Data from Midwives Alliance of North America Statistics Project ( MANA Stats) from 2004-2009
Considerations n=18,343 pregnancies; n=18,397 newborns
Women gave informed consent which allowed their unidentified data to be used in MANA Stats;
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consent also included permission for data to be used in research


Approval for this study was approved by the institutional review board at Oregon State University
Major Variables Studied Waterbirth; Neonates born underwater (n=6534); pregnancies (n=6521)
Intended Waterbirth; Neonates whose mothers intended a waterbirth but did not delivery underwater
(n=1573); pregnancies (n=1570)
Nonwaterbirth; Neonates not born underwater (n=10,290); pregnancies (n=10,252)
Measurement Tool/Data A detailed data collection protocols, reliability, and validity of the MANA Stats 2004-2009 is presented
Collection Method elsewhere
Neonates: 5-minute Apgar score < 7 (yes/no), neonate transfer to hospital (yes/no), infant admission
to hospital during first 6 weeks (yes/no),early and late neonate deaths
Maternal: postpartum reproductive tract infection any time first 6 weeks (uterine infection, UTI, or
delayed perineal healing/infection), postpartum transfer to hospital (yes/no), genital tract trauma
including following categories: none, episiotomy only, degree of perineal tear, required repair, trauma
at multiple sites, trauma not otherwise specified
Data Analysis Logistic regression to analyze dichotomous outcomes (5-minute Apgar score <7, neonate transfer,
NICU admission, infant hospitalization in first 6 weeks, postpartum transfer, postpartum reproductive
tract infection, maternal hospitalization in first 6 weeks, dichotomized trauma)
Multilevel nominal outcomes (genital tract trauma) used multinomial logistic regression
Data analyzed using SPSS 19.0.0.1 and S-Plus Version 8.1
Findings/Discussion Neonatal Outcomes: waterbirths fared better than nonwaterbirths on all neonatal outcome measures
Maternal Outcomes: for waterbirth, 35% reduction in odds of postpartum transfer, 28% reduction in
odds of hospitalization in first 6 weeks, 11% increase in odds of genital tract trauma
Waterbirth neonates had fewer negative outcomes than neonates with a nonwaterbirth
Waterbirth was not associated with infections and had no evidence of neonatal deaths
There is no increased risk for adverse outcomes to neonates with waterbirth, but there may be an
associated risk of genital tract trauma for women
The results are congruent with other studies, and contrary with the ACOG/AAP guidelines, suggesting
that waterbirth is a reasonably safe way to delivery in low-risk births
Appraisal/Worth to practice Women with a low risk pregnancy should consider waterbirthing
Because this was the first cohort study in US, increased risk of tract trauma needs more investigation
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Nurses and doctors should use thus study to educate women interesting in this method of waterbirth
and discuss the risks and benefits found from this study
Clinicians in the meantime should discuss the risk of genital tract trauma as a part of decision making
for waterbirth

First Author Leyla Mollamahmutoglu (2012)/ water birth unit, Womens Health Education & Research Hospital
(Year)/Qualifications
Background/Problem Anxiety and pain triggers the stress response leading to reduced uterine activity & dystocia during labor
Statement Laboring in water may overcome the stress response by promoting relaxation leading to relief of pain
Aim: document the practice of labor in water, assess the effects of water immersion during labor and birth
on maternal, fetal, & neonate well-being and to compare the outcomes & safety with conventional vaginal
deliveries and deliveries with epidural analgesia
Conceptual/theoretical No discussed
Framework
Design/Method/Philosophic Quantitative study
al Underpinnings Interview and observation techniques
Sample/ Setting/Ethical Sample: 610 pregnant women admitted to Zekai Tahir Burak Womens Health Education & Research
Considerations Hospitals between June 2007 and Sept. 2008
Women had to be 37-42 weeks gestational age, no hx of c-sections, intact membranes, absence of
placental abruption/previa, no malpresentation, normal sized fetus, normal results of fetal well-being test
Ethical approval obtained from local research ethics and written informed consent obtained from all
patients
Study conducted in accordance with the basic ethical principles of the Helsinki Declaration
Major Variables Studied Control and two study groups
AN INTEGRATIVE REVIEW 22

Study group 1 is women electing for water birth (n=207)


Study group 2 is vaginal deliveries with epidural analgesia (n=191)
The control group is conventional vaginal deliveries (n=204)
Measurement Tool/Data Women evaluated their birth experience with the visual analog scale (VAS) and a pain scale from 0-10
Collection Method Questionnaire collected demographic data, length of 1 st 2nd 3rd stages of labor, requirements for induction
and episiotomy, perineal trauma, Apgar scores, NICU requirements, & VAS scores
Data Analysis Alpha =0.05 and was accepted for statistical sign value
Data evaluated via SPSS
Compared groups using Chi-square test used for categorical variables
Oneway ANOVE & Bonferroni tests for continuous variables with normal distribution
Kruskall-Wallis oneway ANOVA for continuous non-normal distribution
Findings/Discussion 1st stage of labor shortest in conventional vaginal delivery group
2nd & 3rd stage of labor shortest in water birth group (3 rd stage is delivery of placenta, therefore minimizes
blood loss)
Water birth group had highly significant reduction in induction & episiotomy requirements, lowest VAS
scores (even lower than in women with epidural), lower BP but not significantly, slightly lower Apgar
scores, but higher perineal laceration rate (but were less severe)
No difference in admissions to the NICU between groups, no neonatal infections/adverse perinatal
outcomes/neonatal deaths between either groups
Appraisal/Worth to practice This study, as well as other presented studies discussed in the literature, agree that immersion of water
during labor greatly reduces pain and need for analgesia and requires less obstetric interventions
Rationales were given in the article to further explain risks and benefits to enhance understanding
Water birth is an effective alternative birthing method that should be offered to low risk patients

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