Midwives' experience of their education, knowledge and practice around immersion in water for labour or birth.

Lewis L ，Hauck YL ，Butt J ，Western C ，Overing H ，Poletti C ，Priest J ，Hudd D ，Thomson B ... -  《BMC Pregnancy and Childbirth》

Exploring midwives' perception of confidence around facilitating water birth in Western Australia: A qualitative descriptive study.

the option of labouring and/or birthing immersed in warm water has become widely available throughout hospitals in the United Kingdom and Europe over the last two decades. The practice, which also occurs in New Zealand and interstate in Australia, has until recently only been available in Western Australia for women birthing at home with a small publically funded Community Midwifery Program. Despite its popularity and acceptance elsewhere, birth in water has only recently become an option for women attending some public health services in Western Australia. The Clinical Guidelines developed for the local context that support water birth require that the midwives be confident and competent to care for these women. The issue of competency can be addressed with relative ease by maternity care providers; however confidence is rather more difficult to teach, foster and attain. Clinical confidence is an integral element of clinical judgement and promotes patient safety and comfort. For this reason confident midwives are an essential requirement to support the option of water birth in Western Australia. The aim of this study was to capture midwives' perceptions of becoming and being confident in conducting water birth in addition to factors perceived to inhibit and facilitate the development of that confidence. a modified grounded theory methodology with thematic analysis. four public maternity services offering the option of water birth in the Perth metropolitan area. registered midwives employed at one of the four publicly funded maternity services that offered the option of water birth between June 2011 and June 2013. Sixteen midwives were interviewed on a one to one basis. An additional 10 midwives participated in a focus group interview. three main categories emerged from the data analysis: what came before the journey, becoming confident - the journey and staying confident. Each contained between three and five subcategories. Together they depicted how midwives describe the journey to becoming confident to support women who have chosen the option to water birth and how they are able to retain that confidence once achieved. three key implications emerged from this study, the first was that students and graduate midwives could benefit from the opportunity to work in midwifery led maternity settings that support normal physiological child birth and that accessing such practical placements should be encouraged. Secondly, maternity services would benefit from learning opportunities directed specifically at experienced midwives addressing their particular requirements. Finally, midwives are the custodians of normal physiological birth, attendance at educational days with a focus on supporting this primary role should be mandatory, to inform midwives on current evidence found to support normal birth which includes options such as water birth.

Nicholls S ，Hauck YL ，Bayes S ，Butt J ... -  《-》

Effecting change in midwives' waterbirth practice behaviours on labour ward: an action research study.

the use of water immersion for labour and birth has been shown to be beneficial for women in normal labour (Cluett et al, 2009). It was decided to use problem solving coordinator workshops to change in the way waterbirth practice was promoted and organised on labour ward. Findings from the first Action Research phase (Russell, 2011) led to the development of a waterbirth questionnaire to measure midwives' personal knowledge of waterbirth practice, waterbirth self-efficacy, social support and frequency of hydrotherapy and waterbirth practice. The aim of this paper is to share the questionnaire findings from an on-going action research study. prior to the first workshop 62 questionnaires were distributed to midwives (Bands 5, 6 and 7) working on labour ward. Subsequent questionnaires (n=53) were sent to Bands 5/6 midwives not involved in the workshops, at four (Group 2) and eight months (Group 3). N.B only Bands 5/6 midwives completed post workshop questionnaires. In total 169 questionnaires were distributed. One-way ANOVA with Tukey post-hoc test and the χ(2) test were used to determine statistical significance. 96 questionnaires were returned (57%). Midwives' personal knowledge of waterbirth practice differed significantly between groups, (F2,85=3.67, p<0.05) with midwives in Group 1 giving significantly higher scores (X¯=45.6, 95% CI [43.0, 48.2]), than those in Group 3, (X¯=41.7, 95% CI [40.0, 43.3]), p<0.05. Midwives' waterbirth self-efficacy did not differ significantly between groups (F2,88=3.15, p>0.05). However scores for social support did differ (F2,75=4.011, p=0.022), with midwives in Group 1 giving significantly lower scores (X¯=8.0, 95% CI [6.4, 9.5]) than those in Group 3 (X¯=10.5, 95% CI [9.4, 11.6]), p=0.016. Fifty-five per cent of Group 1 midwives facilitated a waterbirth in the previous three months compared with 87% in Group 3. Changes in the frequency of waterbirth for these groups were statistically significant (x(2)=4.369, p<0.05, df=1). it appears that the co-ordinators were able to influence waterbirth practice because of changes in social support and frequency of waterbirth practice. Given the widespread and continued impact of the intervention, on midwives who attended workshops and those that did not, we feel it likely that a significant proportion of this change could be attributed to the introduction of problem solving waterbirth workshop. The findings from this study suggest that problem solving waterbirth workshops based on an action research format have the potential to normalise midwifery care within medically dominated hospital birthing environments.

Russell K ，Walsh D ，Scott I ，McIntosh T ... -  《-》

Systematic review and meta-analysis to examine intrapartum interventions, and maternal and neonatal outcomes following immersion in water during labour and waterbirth.

Water immersion during labour using a birth pool to achieve relaxation and pain relief during the first and possibly part of the second stage of labour is an increasingly popular care option in several countries. It is used particularly by healthy women who experience a straightforward pregnancy, labour spontaneously at term gestation and plan to give birth in a midwifery led care setting. More women are also choosing to give birth in water. There is debate about the safety of intrapartum water immersion, particularly waterbirth. We synthesised the evidence that compared the effect of water immersion during labour or waterbirth on intrapartum interventions and outcomes to standard care with no water immersion. A secondary objective was to synthesise data relating to clinical care practices and birth settings that women experience who immerse in water and women who do not. Systematic review and meta-analysis. A search was conducted using CINAHL, Medline, Embase, BioMed Central and PsycINFO during March 2020 and was replicated in May 2021. Primary quantitative studies published in 2000 or later, examining maternal or neonatal interventions and outcomes using the birthing pool for labour and/or birth. Full-text screening was undertaken independently against inclusion/exclusion criteria in two pairs. Risk of bias assessment included review of seven domains based on the Robbins-I Risk of Bias Tool. All outcomes were summarised using an OR and 95% CI. All calculations were conducted in Comprehensive Meta-Analysis V.3, using the inverse variance method. Results of individual studies were converted to log OR and SE for synthesis. Fixed effects models were used when I2 was less than 50%, otherwise random effects models were used. The fail-safe N estimates were calculated to determine the number of studies necessary to change the estimates. Begg's test and Egger's regression risk assessed risk of bias across studies. Trim-and-fill analysis was used to estimate the magnitude of effect of the bias. Meta-regression was completed when at least 10 studies provided data for an outcome. We included 36 studies in the review, (N=157 546 participants). Thirty-one studies were conducted in an obstetric unit setting (n=70 393), four studies were conducted in midwife led settings (n=61 385) and one study was a mixed setting (OU and homebirth) (n=25 768). Midwife led settings included planned home and freestanding midwifery unit (k=1), alongside midwifery units (k=1), planned homebirth (k=1), a freestanding midwifery unit and an alongside midwifery unit (k=1) and an alongside midwifery unit (k=1). For water immersion, 25 studies involved women who planned to have/had a waterbirth (n=151 742), seven involved water immersion for labour only (1901), three studies reported on water immersion during labour and waterbirth (n=3688) and one study was unclear about the timing of water immersion (n=215).Water immersion significantly reduced use of epidural (k=7, n=10 993; OR 0.17 95% CI 0.05 to 0.56), injected opioids (k=8, n=27 391; OR 0.22 95% CI 0.13 to 0.38), episiotomy (k=15, n=36 558; OR 0.16; 95% CI 0.10 to 0.27), maternal pain (k=8, n=1200; OR 0.24 95% CI 0.12 to 0.51) and postpartum haemorrhage (k=15, n=63 891; OR 0.69 95% CI 0.51 to 0.95). There was an increase in maternal satisfaction (k=6, n=4144; OR 1.95 95% CI 1.28 to 2.96) and odds of an intact perineum (k=17, n=59 070; OR 1.48; 95% CI 1.21 to 1.79) with water immersion. Waterbirth was associated with increased odds of cord avulsion (OR 1.94 95% CI 1.30 to 2.88), although the absolute risk remained low (4.3 per 1000 vs 1.3 per 1000). There were no differences in any other identified neonatal outcomes. This review endorses previous reviews showing clear benefits resulting from intrapartum water immersion for healthy women and their newborns. While most included studies were conducted in obstetric units, to enable the identification of best practice regarding water immersion, future birthing pool research should integrate factors that are known to influence intrapartum interventions and outcomes. These include maternal parity, the care model, care practices and birth setting. CRD42019147001.

Burns E ，Feeley C ，Hall PJ ，Vanderlaan J ... -  《BMJ Open》

Australian midwives views and experiences of practice and politics related to water immersion for labour and birth: A web based survey.

There is little published research that has examined practitioners' views and experiences of pain relieving measures commonly used during labour and birth, particularly for non-pharmacological measures such as water immersion. Furthermore, there is minimal published research examining the process of policy and guideline development, that is, the translation of published research to usable practice guidance. The aims of phase three of a larger study were to explore midwives knowledge, experiences and support for the option of water immersion for labour and birth in practice and their involvement, if any, in development of policy and guidelines pertaining to the option. Phase three of a three phased mixed methods study included a web based survey of 234 Australian midwives who had facilitated and/or been involved in the development of policies and/or guidelines relating to the practice of water immersion. Midwives who participated in this study were supportive of both water immersion for labour and birth reiterating documented benefits of reduced pain, maternal relaxation and a positive birth experience. The most significant concerns were maternal collapse, the difficulty of estimating blood loss and postpartum haemorrhage whilst barriers included lack of accredited staff, lifting equipment and negative attitudes. Midwives indicated that policy/guideline documents limited their ability to facilitate water immersion and did not always to support women's informed choice. Midwives who participated in this study supported the practice of water immersion reiterating the benefits documented in the literature and minimal risk to the woman and baby. The Human Research Ethics Committee of the University of South Australia approved the research.

Cooper M ，Warland J ，McCutcheon H 《-》