Cluett (2006) Randomised controlled trail of labouring in water compared with standard of aumgentation for management of dystocia in first stage of labour

Papers
Randomised controlled trial of labouring in water compared with
standard of augmentation for management of dystocia in first stage
of labour
Elizabeth R Cluett, Ruth M Pickering, Kathryn Getliffe, Nigel James St George Saunders
Abstract
ObjectivesTo evaluate the impact of labouring in water during
first stage of labour on rates of epidural analgesia and operative
delivery in nulliparous women with dystocia.
Design Randomised controlled trial.
Setting University teaching hospital in southern England.
Participants 99 nulliparous women with dystocia (cervical
dilation rate 1 cmhour in active labour) at low risk of
complications.
Interventions Immersion in water in birth pool or standard
augmentation for dystocia (amniotomy and intravenous
oxytocin).
Main 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 Women randomised to immersion in water had a lower
rate of epidural analgesia than women allocated to
augmentation (47% v66%, relative risk 0.71 (95% confidence
interval 0.49 to 1.01), number needed to treat for benefit (NNT)
5). They showed no difference in rates of operative delivery
(49% v50%, 0.98 (0.65 to 1.47), NNT 98), but significantly fewer
received augmentation (71% v96%, 0.74 (0.59 to 0.88), NNT 4)
or any form of obstetric intervention (amniotomy, oxytocin,
epidural, or operative delivery) (80% v98%, 0.81 (0.67 to 0.92),
NNT 5). More neonates of women in the water group were
admitted to the neonatal unit (6 v0, P = 0.013), but there was no
difference in Apgar score, infection rates, or umbilical cord pH.
Conclusions Labouring in water under midwifery care may be
an option for slow progress in labour, reducing the need for
obstetric intervention, and offering an alternative pain
management strategy.
Introduction
Slower than expected progress in the first stage of labour (dysto-
cia) occurs in 20% of nulliparous women in labour and accounts
for 20% of caesarean sections and 40% of instrumental
deliveries, and results in longer hospitalisation.
1For women at
low risk of complications, it marks the transition from midwifery
to obstetric management. Since proponents of active manage-
ment first claimed the benefits of shorter labour and lower rates
of caesarean section,
23debate has continued over conservative
versus aggressive management and the medicalisation of birth.
Management strategies for dystocia vary from immediate augmentation
45to delayed intervention up to four hours after
diagnosis.68Comparison between strategies is difficult as specific
features often differ; for example, one-to-one care is recognised
to have beneficial effect on labour outcomes.
9
Our current trial was based on two precepts. Firstly, that
incomplete understanding of labour may lead to unnecessarily
early intervention. Secondly, that anxiety and pain may trigger a
stress response,
10leading to reduced uterine activity and
dystocia.11Labouring in water may ameliorate this stress
response by aiding relaxation and pain relief. Few trials have
evaluated labouring in water, perhaps because of the difficulty in
randomising women who may have strong preferences.
12A
Cochrane review concluded that, for women at low risk of com-
plications, there was no clear evidence of advantage or disadvan-
tage in using a pool in labour but further research was needed.
13
Two national surveys concluded that labour and birth in water
had no effect on perinatal mortality.14 15
In preparation for the trial reported here, we conducted a
feasibility study comparing labour in water with augmentation
and conservative management for women with dystocia,
16but
conservative management was considered unacceptable by
women and clinicians. Our current trial therefore compares
labour in water with augmentation in nulliparous women with
dystocia.
Participants and methods
Design
Our randomised controlled trial compared immersion in water
during the first stage of labour after diagnosis of dystocia with
augmentation, the standard management for dystocia. We
conducted the trial between January 1999 and December 2000
in a large university teaching hospital in southern England with
about 4500 births a year.
Study population
Nulliparous women with a diagnosis of dystocia (cervical dilation
of 1 cmhour)
who at that time would routinely have been
advised to have their labour augmented by amniotomy or
oxytocin infusion, or both
were eligible for the trial if they were
able to give informed consent, had received information about
the trial during their pregnancy (a leaflet describing the trial was
distributed to all nulliparous women antenatally), were in
spontaneous, active labour, and were at low risk of complications
(full term, singleton pregnancies, fetus in cephalic presentation,
and no medical, obstetric, or psychiatric problems).
Cite this article as: BMJ, doi:10.1136bmj.37963.606412.EE (published 26 January 2004)
BMJ Online First bmj.compage 1 of 6
on 24 April 2006
bmj.com
Downloaded from

Intervention
After participating women were randomised, each management
option consisted of a package of care provided by midwives,
including one-to-one care. Labour progress was assessed by
vaginal examinations every four hours and documented on a
standard partogram. All women could request any form of
analgesia available at any time.Augmentation Women in the augmentation group received
the standard management for dystocia. Amniotomy was
performed if the membranes were intact, and a midwife
managed the labour for the next two hours unless otherwise
clinically indicated. If the membranes were already ruptured or
progress was not satisfactory during the two hours after
amniotomy, intravenous oxytocin was given, starting at 4
mUmin and doubled every 30 minutes, up to a maximum of 64
mUmin, until regular contractions (3-4 every 10 minutes)
occurred. Continuous fetal monitoring was carried out. Labour in water Women allocated to labour in water used a
permanent, acrylic, oval waterbirth pool measuring 154 cm by
184 cm by 77 cm and filled with still tap water without additives
so that immersion was to above the breasts when sitting. Water
temperature was maintained at 36.0-37.0C. The maximum stay
in the pool before reassessment by vaginal examination was four
hours. If labour progress was satisfactory (cervical dilation 1 cmhour), subsequent care could continue in the pool if the
woman wished, otherwise augmentation was advised.
Sample size
We based our estimate of the potential effect size on an audit of
50 nulliparous women with dystocia in May-July 1997, who
would have met the trial inclusion criteria. We concluded that
220 women would be required to detect an absolute reduction of
25% in the rate of epidural analgesia (from 60% to 35%) and an
absolute reduction of 20% in the operative delivery rate (from
40% to 20%) with 90% power in 5% two sided tests. The local
incidence of dystocia in nulliparous women meeting our eligibil-
ity criteria was about five a week (260 a year). In our pilot study
we obtained a consent rate of 71%,
16but we anticipated a lower
rate when all midwives undertook recruitment, and therefore
planned a recruitment period of two years.
Randomisation and recruitment
We used a computer generated randomisation schedule in
balanced blocks of 20. Concealment was ensured by an
independent person putting allocation details in sequentially
numbered, opaque, sealed envelopes. Ten consecutively num-
bered envelopes were stored in the labour ward at any one time
and audited daily to ensure they were intact. After dystocia was
diagnosed, a midwife who had received training in patient
recruitment checked that the woman in question had received
the information leaflet about the trial, assessed her eligibility for
the study, and, if suitable, sought her informed consent. When a
woman agreed to participate the midwife opened the next trial
envelope to allocate the woman to a treatment arm and to give
her a unique trial number. Participation in the trial was recorded
in the womans routine maternity records.
Outcome measures
Primary outcome measures were epidural analgesia and
operative delivery (ventouse, forceps, or caesarean section). Sec-
ondary measures included augmentation rates (receiving
amniotomy or oxytocin, or both) and maternal or neonatal mor-
bidity (any infection, admission to the neonatal unit, or condition
that required medical care up to the 10th postpartum day).
Obstetric data were recorded in the maternity records by practi- tioners and abstracted after discharge from maternity care. It was
not possible to conceal allocation from clinical practitioners or at
the time of data abstraction as care provided was clearly
documented. However, as data were objective in nature and
recorded contemporaneously observer bias was minimised.
We conducted a postpartum structured interview in the
maternity unit to assess retrospectively the womens experience
of pain at 30 minutes after the intervention started and change
in pain over the same time period (measured with visual
analogue scales of 0 to 100 mm for pain experience and 50 mm
to +50 mm for change in pain). We did not assess pain
concurrently because of the disruption to the women and
midwives. We also assessed womens satisfaction overall and in
relation to privacy and freedom of movement (asked as separate
questions) using four point Likert scales. We chose to use a struc-
tured interview format to reduce potential bias because it was not
possible to keep the interviewer blinded to womens treatments
as their comments made the allocation apparent.
Statistical analysis
We analysed results on an intention to treat basis. We compared
rates of epidural analgesia and operative delivery between
groups using Pearsons 2 tests and presented results as relative
risks with 95% confidence intervals. When numbers were small
we calculated exact P values and confidence intervals in
StatXact-5. We produced numbers needed to treat to produce
benefit in one woman and calculated confidence intervals as the
inverse of the confidence interval about the absolute risk differ-
ence. Confidence intervals around the numbers needed to treat
for non-significant differences include the numbers needed to
treat to produce harm,
17showing that results are not inconsistent
with the intervention producing worse outcome. We used Mann-
Whitney tests to compare length of labour and womens pain
and satisfaction scores, and presented confidence intervals for
differences in means. A confidential summary of the safety data was prepared after
50 women had been randomised, and assessed by an obstetric
consultant independent of the trial, who recommended that
recruitment continue.
Results
Recruitment
Of 3825 nulliparous women who delivered in the unit during the
two years of recruitment, 741 were defined as being at low risk of
complications at the time of the diagnosis of dystocia (see figure).
Consent was sought from 176 eligible women, of whom 99
(56%) agreed to participate, and were randomised. The two
groups of women showed no important differences in baseline
characteristics (table 1). There was good adherence to the trial
protocol, with 48 of the 49 women allocated to labour in water
using the pool, and 48 of the 50 women allocated to standard
care receiving augmentation. The woman who declined to enter
the water requested an amniotomy. Two women in the augmen-
tation group progressed before augmentation could be started.
Primary outcomes
Twenty three women (47%) allocated to labour in water received
epidural analgesia after randomisation compared with 33 (66%)
in the augmentation group (relative risk 0.71 (95% confidence
interval 0.49 to 1.01), number needed to treat 5) (table 2). The
numbers of operative deliveries (caesarean sections and
ventouse and forceps deliveries) were similar in both arms of the
trial, with 24 (49%) women allocated to labour in water receiving
an operative delivery compared with 25 (50%) women allocated
Papers
page2of6BMJ Online First bmj.com
on 24 April 2006
bmj.com
Downloaded from

to augmentation (relative risk 0.98 (0.65 to 1.47), number needed
to treat 98).
Secondary outcomes
Twenty five of the 27 women in the water labour arm who had
made slow progress at the assessment four hours after
recruitment received augmentation. A further three women pro-
gressed slowly subsequently and also received augmentation.
Seven women who progressed satisfactorily received anamniotomy for other indications. The number of women who
received augmentation (amniotomy or oxytocin) in the water
labour arm was significantly lower than that in the standard care
arm (35 (71%)
v48 (96%), relative risk 0.74 (0.59 to 0.88),
number needed to treat 4) (table 2). The mean duration of the first stage of labour was similar in
the two groups, 10.47 hours in the water labour group and 10.26
hours in the augmentation group (table 3). Women allocated to
labour in water reported significantly lower mean pain scores at
30 minutes after start of the allocated management (49 mm v64
mm) and a reduction in mean pain (26 mm) compared with an
increase for women receiving augmentation (12 mm). Women
allocated to labour in water were more likely to report
satisfaction with freedom of movement (91% v63%) and with
experience of privacy (96% v81%), but there was no difference
between groups in overall satisfaction (table 3).
Maternal and neonatal wellbeing
Maternal and neonatal infection rates were similar in the two
groups (table 4), as was neonatal condition at birth indicated by
Apgar score and umbilical cord pH. Six neonates born to women
in the water labour group were admitted to the neonatal unit
compared with none in the augmentation group (P = 0.013). The
reasons for admission were: cardiac defects (1), hypothermia (2),
fever (1), suspected infection on day 2 (1), and poor feeding on
day 3 (1). There was a mean delay of 6 hours (range 2-10 hours)
between women leaving the pool and birth. With the exception
of the infant with cardiac defects, all these neonates, who had
required an operative delivery, were reunited with their mothers
within 48 hours and experienced no subsequent problems.
Discussion
This is the first trial to evaluate the impact of labouring in water
for nulliparous women with dystocia. Compared with women
given standard augmentation, the women labouring in water had
no difference in operative delivery rates and tended to receive
less epidural analgesia. Before this trial it had been suggested
that as all the women would have dystocia, augmentation would
be inevitable, along with longer labour, andor assistance in the
second stage of labour. However, almost 30% of women in the
water arm did not receive augmentation and 20% received no
obstetric intervention, without evidence of longer labour, both of
these rates being significantly different from the augmentation
arm. In addition, women retrospectively reported less pain and
increased satisfaction. Our findings suggest that delaying augmentation in
association with a supportive environment (water immersion) is
acceptable to women with dystocia and may reduce the need for
epidural analgesia without increasing labour length or operative
deliveries. This is important, as it has been suggested that women
prefer earlier intervention.
7Also a management approach that
reduces rates of augmentation and associated obstetric interven-
tion may contribute positively to maternal physiological and
psychological health: oxytocin infusion is known to increase the
risk of uterine hyperstimulation and fetal hypoxia, and obstetric
interventions are associated with lower maternal satisfaction.
18A
reduced need for epidural analgesia and augmentation may
enable staff and other resources to be used differently
for
example, allowing more women to receive one-to-one care in
labour.
Maternal and neonatal wellbeing
The trial was not large enough to detect differences in maternal
and fetal morbidity. However, indicators of wellbeing were simi-
Nulliparous women who gave
birth during study period (n=3825)Women ineligible for study
(n=338)
Reasons (some women have
more than 1):
Epidural in situ (n=94)
Fetal distress (n=111)
Transfer into maternity unit
(n=62)
Already in pool (n=31)
Misdiagnosis of labour (n=34)
Not English speaking (n=12)
Woman unwell (n=10)
Age 16 years (n=2)
Women declined to
participate (n=77)
Reasons:
Requested epidural (n=31)
Specific care requested (n=13)
Specific care declined (n=18)
Declined trial (n=5)
Unknown (n=10)
Nulliparous women at low
risk of obstetric complication at start of labour (n=2218)
Women having dystocia (n=741)
Women from whom
consent sought (n=176)
Women randomised to treatment (n=99)
Augmentation (n=50)Water immersion (n=49)
Women eligible for
study entry (n=403)
Postnatal interview (n=48)Postnatal interview (n=47)
Maternity record review (n=50)Maternity record review (n=49)
Flow of participants through trial
Table 1 Baseline characteristics of nulliparous women with dystocia
allocated to labour in a birth pool or standard augmentation (amniotomy
and intravenous oxytocin). Values are numbers (percentages) of women
unless otherwise indicated
Characteristics Labour in water (n=49) Augmentation (n=50)
Mean (SD, range) maternal age (years) 26.0 (4.8, 17-37) 24.8 (6.0, 17-38)
Gravida: 1 39 (80) 36 (72)
2 7 (14) 11 (22)
3 3 (6) 3 (6)
Mean (SD, range) birth weight (g) 3502 (427, 2640-4630) 3417 (484, 2450-4810)
Mean (SD, range) gestational age at start of labour (days) 284 (7, 264-294) 280 (8, 260-294)
Marital status: Single 16 (33) 21 (42)
Married 23 (47) 23 (46)
Stable relationship 10 (20) 6 (12)
Mean (SD, range) cervical dilation (cm):
When labour established 4.24 (1.12, 3.0-8.0) 4.22 (1.14, 3.0-8.0)
When dystocia diagnosed 5.31 (1.41, 3.0-8.5) 5.26 (1.41, 3.0-9.0)
When randomised 5.31 (1.40, 3.0-8.5) 5.28 (1.37, 3.0-9.0)
Mean (SD, range) cervical dilation between start of
labour and randomisation
(cmhour) 0.27 (0.24,
0.22-0.72) 0.25 (0.28, 0.38-1.2)
Papers
BMJ Online First bmj.compage 3 of 6
on 24 April 2006
bmj.com
Downloaded from

lar in the two groups, with the exception of increased admission
to the neonatal unit after labour in water. Possible reasons for
this include the water immersion itself, the delay in intervention
of up to four hours (even though this did not affect overall labour
length), extra caution by practitioners when women were known
to have laboured in water, or chance factors with no direct rela-
tion to the trial. No other studies of labour in water have
reported such an association: instead, they either did not provide
data on admissions to neonatal units
19 20or reported only one
admission21or similar admission rates in both trial arms.22Eckert et al reported an increased incidence of initial resuscitation
measures with water immersion,
22but we found no difference in
Apgar scores and blood gas analysis at birth. Indeed, three of the
admissions to the neonatal unit were between nine and 48 hours
after delivery, while the three admissions immediately after birth
were associated with temperature regulation. Comparative stud-
ies of labour in water found no increase in admissions to
neonatal units or other markers of neonatal distress.
2325It is
clearly important to ensure ongoing audit of neonatal outcomes
for women who labour in water.
Table 2 Epidural analgesia, mode of delivery, and secondary outcomes among nulliparous women with dystocia allocated to labour in a birth pool or
standard augmentation (amniotomy and intravenous oxytocin). Values are numbers (percentages) of women unless otherwise indicated
Outcomes Labour in water (n=49) Augmentation (n=50) Relative risk (95% CI) Number needed to treat to
benefit one woman (NNTB) (95% CI) Pearson 2 P value
Epidural analgesia: At first stage of labour 21 (43) 30 (60)
At second stage of labour 2 (4) 3 (6)
At any stage of labour 23 (47) 33 (66) 0.71 (0.49 to 1.01) 5 (3 to to NNTH 212) 0.056
Mode of delivery: Normal 25 (51) 25 (50)
Ventouse 12 (25) 10 (20)
Forceps 4 (8) 4 (8)
Caesarean section 8 (16) 11 (22)
Any operative delivery 24 (49) 25 (50) 0.98 (0.65 to 1.47) 98 (3 to to NNTH 5) 0.919
Method of augmentation: Amniotomy 28 (57) 37 (74)Amniotomy alone 14 (29) 20 (40)
Oxytocin 21 (43) 28 (56) Oxytocin alone 7 (14) 11 (22)
Amniotomy and oxytocin 14 (29) 17 (34)
Amniotomy or oxytocin, or
both 35 (71) 48 (96) 0.74 (0.59 to 0.88) 4 (3 to 9) 0.001
Any obstetric intervention* 39 (80) 49 (98) 0.81 (0.67 to 0.92) 5 (3 to 14) 0.004
NNTH=Number needed to treat to harm one woman.
*Amniotomy, oxytocin, epidural analgesia, or operative delivery.
Table 3 Labour length and retrospectively reported pain and satisfaction among nulliparous women with dystocia allocated to labour in a birth pool or
standard augmentation (amniotomy and intravenous oxytocin). Values are numbers (percentages) of women unless otherwise indicated
Outcomes Labour in water (n=49) Augmentation (n=50) Mean differences (95% CI) P value
Mean (SD, range) length of first stage of labour (hours) 10.47 (3.69, 3.75-19.32) 10.26 (3.75, 4.25-21.37) 0.22 (
1.27 to 1.70) 0.677
Pain score (visual analogue scale)*: Mean (SD, range) pain score 30 minutes
after start of management (0-100 mm) 49 (22, 8-96) 64 (30, 0-100)
16 ( 27 to 5) 0.003
Mean (SD, range) change in score after
30 minutes of management ( 50 to 50
mm)
26 (16, 50-28) 12 (32, 50-50) 38 ( 49 to 28) 0.001
Maternal satisfaction (n=47)* (n=48)* Relative risk of satisfaction (95% CI)
With freedom of movement: Satisfied 43 (91) 30 (63)
1.46 (1.18 to 1.91) 0.001
Satisfied and dissatisfied 4 (9) 15 (31)
Dissatisfied 0 0
Not sure 0 3 (6)
With privacy: Satisfied 45 (96) 39 (81)
1.18 (1.02 to 1.42) 0.029
Satisfied and dissatisfied 2 (4) 9 (19)
Dissatisfied 0 0
Not sure 0 0
With overall management: Satisfied 44 (94) 42 (88)
1.07 (0.93 to 1.26) 0.486
Satisfied and dissatisfied 2 (4) 6 (13)
Dissatisfied 1 (2) 0
Not sure 0 0
*Postnatal interviews were conducted for 48 women allocated to augmentation and 47 women allocated to labour in water. A further two women in each grou p declined to answer the pain
questions.
Mann-Whitney test. Pearson
2test. Exact2and confidence interval.
Papers
page4of6BMJOnline First bmj.com
on 24 April 2006
bmj.com
Downloaded from

Limitations of study
Only 99 of the intended 220 women were recruited for a variety
of reasons. In common with other trials
18epidural analgesia was
the main reason why nulliparous women with dystocia were
ineligible for our study (28%). Local rates of epidural analgesia
and their likely impact on recruitment should feature as part of
the planning of any future trials involving labour management.
In our busy maternity unit recruitment was not a priority, and
some eligible women were not invited to participate in our study.
The main reason eligible women chose not to enter the trial was
a preference for one or other form of care (40%). This is a recog-
nised problem, and consideration is needed on how this may
affect the generalisability of our findings and ways to overcome
recruitment problems. Recruitment became more difficult towards the end of the
trial because of the adoption of a more conservative approach to
managing dystocia in the unit and the introduction of the modi-
fied World Health Organization partogram,
6which incorporates
a delay between the identification of slow progress and augmen-
tation. During this delay midwives could facilitate ongoing
conservative management; as a consequence, they were less will-
ing to recruit women to the trial, knowing that half of the women
would immediately receive augmentation. Thus, the trial was not
continued past the planned two years. The low recruitment rate
contributed to the outcomes achieved, such as the lack of statisti-
cal significance in relation to the difference in rates of epidural
analgesia.
We thank the women who participated in the trial; the midwives and obstet-
ric and support staff of the unit where the trial was conducted; research
advisory group members Maggie Elliot and Debbie Gould; and Rona
McCandlish for her support in preparing this paper.
Contributors: ERC was principal investigator and research midwife and was
responsible for trial design and coordination, and data collection and
analysis, supported by RMP and KG as research supervisors. NJS contributed to the initial idea and enabled the trial in the clinical setting. All
authors helped to write the paper. ERC acts as guarantor for the paper.
Funding: Southampton University Hospitals NHS Trust.
Competing interest: None declared.
Ethical approval: Approval was given by the local research ethics
committee.
1 Department of Health.
NHS mater nity statistics, England 198990 to 199495. Statistical
Bulletin No 28 . London: Stationery Office, 1997:1-16.
2 Johanson R, Newburn M, MacFarlane A. Has the medicalisation of childbirth gone too far? BMJ 2002;324:892-5.
3 Impey L, Boylan P. Active management of labour revisited. Br J Obstet Gynaecol
1999;106:183-7.
4 Cammu H, Van Eeckhout E. A randomised controlled trial of early versus delayed use of amniotomy and oxytocin infusion in nulliparous labour. Br J Obstet Gynaecol
1996;103:313-8.
5 Sadler LC, Davison T, McCowen LME. A randomised controlled trial and meta analy- sis of active management of labour. Br J Obstet Gynaecol2000;107:909-15.
6 World Health Organisation maternal health and safe motherhood programme. World Health Organisation partograph in the management of labour. Lancet1994;343:1399-
404.
7 Blanch G, Lavender T, Walkinshaw S, Alfirevic A. Dysfunctional labour: a randomised trial. Br J Obstet Gynaecol 1998;105:117-20.
8 Lavender T, Walkinson S, Walton I. A prospective study of womens views of factors contributing to a positive birth experience Midwifer y1999;15:40-6.
9 Hodnett ED. Support from caregivers during childbirth. (Cochrane review) In: Cochrane Librar y . Issue 1. Oxford: Update Software, 2003.
10 Brownridge P. The nature and consequence of childbirth pain. Eur J Obstet Gynecol
Reprod Biol 1995;32(suppl):S9-15.
11 De Punzio C, Neri E, Metelli P, Bianchi MS, Venticinqui M, Ferdeghini M, et al. The relationship between maternal relaxation and plasma beta endorphin levels during
parturition. J Psychosom Obstet Gynaecol 1994;15:205-10.
12 Garland D, Jones K. Waterbirth, first stage immersion or non immersion? Br J Midwifer y
1994;2(3):113-20.
13 Nikodem VC. Immersion in water during pregnancy, labour and birth. In: Cochrane
Librar y . Issue 1. Oxford: Update Software, 2003.
14 Gilbert RE, Tookey PA. Perinatal mortality and morbidity among babies delivered in water; surveillance study and postal survey. BMJ1999;319:483-7.
15 Alderdice F, Renfrew M, Marchant S, Ashurst H, Hughes P, Berridge G, et al. Labour and birth in water in England and Wales. BMJ1995;310:837.
16 Cluett ER, Pickering RM, Brooking JI. An investigation into the feasibility of compar- ing three management options (augmentation, conservative and water) for nulliparae
with dystocia in the first stage of labour. Midwifer y2001;17:35-43.
17 Altman DG. Confidence intervals for the number needed to treat. BMJ1998;317:1309-
12.
18 Green JM, Coupland VA, Kitzinger JV. Great expectations. A prospective study of womens
expectations and experiences of childbirth . 2nd ed. Cheshire: Books for Midwives, 1998.
19 Schorn MN, McAllister JL, Blanco JD. Water immersion and the effect on labor. J Nurse
Midwifer y 1993;38:336-42.
20 Rush J, Burlock S, Lambert K, Loasley-Milman M, Hutchinson B, Enkin M. The effects of whirlpool baths in labour: a randomised controlled trial. Birth1996;23:136-43.
21 Cammu H, Clasen K, Wettere L, Derde M-P. To bathe or not to bathe during the first stage of labor. Acta Obstet Gynecol Scand 1994;73:468-72.
22 Eckert K, Turnbull D, MacLennan A. Immersion in water in the first stage of labour: a randomised controlled trial. Birth2001;28:84-93.
23 Aird IA, Luckas MJM, Buckett WM, Bousfielf P. Effects intrapartum hydrotherapy on labour parameters. Aust N Z J Obstet Gynaecol 1997;37:137-42.
24 Otigbah CM, Dhanjal MK, Harmsworth G. A retrospective comparison of water births and conventional vaginal deliveries. Eur J Obstet Gynecol Reprod Biol2000;91:15-20.
Table 4Maternal and neonatal morbidity, including infection, for nulliparous
women with dystocia allocated to labour in a birth pool or standard
augmentation (amniotomy and intravenous oxytocin). Values are numbers
(percentages) unless otherwise indicated
Outcomes Labour in water
(n=49) Augmentation (n=50) P value
Maternal wellbeing
Infection in first 10 days 3 (6) 5 (10) 0.715*
Neonatal wellbeing
Apgar score at 5 minutes: 8 1 (2) 0 0.203
9 40 (82) 47 (94)
10 8 (16) 3 (6)
Mean (SD, range) arterial umbilical cord pH 7.26 (0.07,
7.10-7.39) 7.25 (0.07, 7.11-7.36) 0.965
Admission to neonatal unit in first 10 days 6(12) 0 0.013*
Infection in first 10 days: 8 (17) 9 (18) 0.783 Eye(s) 5 6
Mouth 2 2
Umbilicus 0 1
Skin 1 0
Penis 1 1
Raised white cell count 1 0
Raised C reactive
protein level 01
*Exact
2test.
Mann-Whitney test.
Umbilical cord pH analysis undertaken in only 35 neonates from labour in water group and
39 from augmentation group.
Some neonates had more than one condition.
Pearson
2test.
What is already known on this topic
For women in normal labour, immersion in water is
associated with less need for analgesia and increased
satisfaction
Augmentation of labour, in particular oxytocin
administration, is associated with hyperstimulation and
decreased maternal satisfaction
What this study adds
For nulliparous women with dystocia (cervical dilation 1
cmhour), immersion in water for up to four hours seemed
to reduce need for augmentation of labour, reduce pain,
and increase satisfaction, without increasing overall length
of labour or operative delivery rate
Water immersion may be an alternative option to early
augmentation of labour
Papers
BMJOnline First bmj.compage 5 of 6
on 24 April 2006
bmj.com
Downloaded from

25 Ohlsson G, Buchhave P, Leandersson U, Nordstrom L, Rydhstrom H, Sjolin I. Warmtub bathing during labor; maternal and neonatal effects. Acta Obstet Gynecol Scand
2001;80:311-4.
(Accepted 18 November 2003)
doi 10.1136bmj.37963.606412.EE
Nightingale Building (67), University of Southampton, Southampton SO17 1BJ
Elizabeth R Cluett lecturer in midwifer y Kathryn Getliffe
professor of nursing
Medical Statistics Group, Health Care Research Unit (805), Southampton General
Hospital, Southampton SO16 6YD
Ruth M Pickering senior lecturer in medical statistics
Trust Management Office (Mail point 18), Southampton General Hospital,
Southampton SO16 6YD
Nigel James St George Saunders medical director
Correspondence to: E R Cluett ec1@soton.ac.uk
Papers
page6of6BMJ Online First bmj.com
on 24 April 2006
bmj.com
Downloaded from