Labouring in water

Editor—The study by Cluett et al, comparing labour in water with standard augmentation for dystocia, tackles an important area.¹ Too often modern obstetrics concentrates on major medical interventions and neglects the low tech solutions that many women would prefer.²

Despite the study's robust design the findings do not fully support the conclusions. Neither of the primary outcomes (epidural rates and assisted delivery rates) differed significantly between the two groups: only by combining all outcome measures was there a significant difference in medical intervention overall. One conclusion not emphasised is that labour in the pool is associated with significantly more neonatal morbidity, with six babies from this group admitted to special care and none from the standard augmentation group (P = 0.013).

Inadequate numbers may be responsible for the absence of a significant difference in epidural rates. As discussed by Cluett et al, recruitment to randomised controlled trials of obstetric intervention is often difficult. Many women have preconceived ideas about how they would like their labour to be managed and are unwilling to be randomly allocated management.

Figure 1.

It is therefore particularly unfortunate that the authors' attempts to address this important question seem not to have been supported by local policy makers. The unit's adoption of a more conservative approach to augmentation half way through the study seems to have been based on pre-existing research³ rather than any contemporaneously published report. Surely it would have been ethical to delay such a policy change until the researchers had completed recruitment?