Optimal outcomes of labor and birth in water compared to standard maternity care

Background. Eleven randomized controlled trials have demonstrated that warm water immersion during labor (WL) safely and effectively reduces obstetric pain. Data are less conclusive regarding underwater birth (WB), although excellent outcomes have been reported for 25,000 cases. This study was designed to address the lack of literature about inpatient WB in the United States, despite availability in 300 hospitals.;Methods. A retrospective cohort study of 13,394 births was conducted at a California community hospital during the first ten years intrapartum immersion was available; 624 WL (4.7%) and 675 WB (5.0%) were identified. Logistic regression and analyses of variance were used to compare perinatal optimality (Optimality Index-United States ratings), care processes and outcomes among three study groups (WL, WB, and standard care), after controlling for medical and obstetric risk factors.;Results. Nurse-midwives were the provider type most likely to furnish hydrotherapy (93.6%). WL and WB were most common among English-speaking, nulliparous women with a college or graduate education. Hydrotherapy was associated with specific midwives and labor nurses. Use of pharmacological pain relief methods was five times greater in the non-immersion group than the WB group (OR=5.7, 99% CI=4.0-6.2, p<.0001). Severe perineal laceration was decreased in the WB group relative to the standard care group (p<.0001), although obstetric laceration repair (p<.0001) and periurethral laceration (p<.0001) were increased. WB was also associated with decreased labor augmentation (p<.0001), fewer prophylactic and therapeutic antibiotics (p<.0001), and intermittent versus continuous fetal monitoring (p<.0001) compared to the non-immersion and WL groups. There were no other differences in maternal or neonatal parameters including method of delivery, Apgar scores and nursery admission.;Conclusions. WB was associated with optimal perinatal outcomes and reductions of intrapartum medications and technologic care processes. Although increased periurethral laceration and laceration repair were associated with WB, this was balanced by decreased severe perineal laceration. Data support the use of hydrotherapy during labor and birth by healthy women who self-select with informed consent. Findings highlight the impact that midwives and nurses have on women's decision-making for pain relief during childbirth.