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An Integrative Review
Lindsey A. Brookmire
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
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
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.
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
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.
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
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,
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.
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,
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
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
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
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
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.
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
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
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 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
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
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
Burns, E. E., Boulton, M. G., Cluett, E., Cornelius, V. R., & Smith, L. A. (2012). Characteristics,
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,
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
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
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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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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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
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