16. (4.) Results by individual review ‐ immersion in water.
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4. Immersion in water in labour and birth, 12 studies, 3252 women (Cluett 2009) | |||
| 4.1. Immersion versus no immersion in the first stage of labour (10 studies, 2932 women) | Outcome | No. of studies (no. women) | Results |
| Pain intensity – mean visual analogue pain scores (VAS) at the start of assessment period | 2 (141) | MD ‐0.01, 95% CI ‐0.54 to 0.52, no difference between groups in pain intensity | |
| Pain intensity ‐ mean visual analogue pain scores (VAS) up to one hour after the start of assessment | 2 (141) | MD ‐0.81, 95% CI ‐1.34 to ‐0.28, no difference between groups in pain intensity | |
| Pain intensity ‐ Ordinal description as moderate to severe, 30 mins after randomisation |
1 (120) | RR 0.75, 95% CI 0.62 to 0.91, significantly fewer women in the immersion group experienced moderate to severe pain | |
| Pain intensity ‐ VAS scale 8 to 10, 30 mins after randomisation |
1 (120) | RR 0.72, 95% CI 0.58 to 0.90, significantly fewer women in the immersion group had VAS score of 8 to 10 |
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| Pain intensity ‐ Ordinal scale pain faces 4 to 5, 30 mins after randomisation |
1 (120) | RR 0.67, 95% CI 0.51 to 0.90, significantly fewer women in the immersion group had pain faces 4 to 5 on pain scale |
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| Pain intensity ‐ Ordinal description as moderate to severe, 1 hr after randomisation |
1 (117) | RR 0.76, 95% CI 0.63 to 0.91, significantly fewer women in the immersion group experienced moderate to severe pain |
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| Pain intensity ‐ VAS scale 8 to 10, 1 hr after randomisation |
1 (117) | RR 1.21, 95% CI 0.69 to 2.11, no evidence of a significant difference between groups |
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| Pain intensity ‐ Ordinal scale pain faces 4 to 5, 1 hr after randomisation |
1 (117) | RR 0.68, 95% CI 0.53 to 0.86, significantly fewer women in the immersion group had pain faces 4 to 5 on pain scale |
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Pain intensity ‐ Ordinal description as moderate to severe, 2 hrs after randomisation | 1 (57) | 0.76, 95% CI 0.59 to 0.98, significantly fewer women in the immersion group experienced moderate to severe pain |
| Pain intensity ‐ VAS scale 8 to 10, 2 hrs after randomisation | 1 (57) | RR 0.83, 95% CI 0.66 to 1.05, no evidence of a significant difference between groups | |
| Pain intensity ‐Ordinal scale pain faces 4 to 5, 2 hrs after randomisation | 1 (57) | RR 0.72, 95% CI 0.52 to 0.98, significantly fewer women in immersion group had pain faces 4 to 5 on pain scale | |
| Pain intensity ‐ Ordinal description as moderate to severe, 3 hrs after randomisation | 1 (32) | RR 0.52, 95% CI 0.23 to 1.16, no evidence of a significant difference between groups | |
| Pain intensity ‐ VAS scale 8 to 10, 3 hrs after randomisation | 1 (32) | RR 0.69, 95% CI 0.39 to 1.23, no evidence of a significant difference between groups | |
| Pain intensity ‐ Ordinal scale pain faces 4 to 5, 3 hrs after randomisation | 1 (32) | RR 0.57, 95% CI 0.25 to 1.27, no evidence of a significant difference between groups | |
| Pain intensity ‐ Ordinal description as moderate to severe, 24 hrs after randomisation | 1 (119) | RR 0.64, 95% CI 0.50 to 0.82, significantly fewer women in the immersion group experienced moderate to severe pain | |
| Pain intensity ‐ VAS scale 8 to 10, 24 hrs after randomisation | 1 (119) | RR 0.62, 95% CI 0.49 to 0.80, significantly fewer women in the immersion group had VAS score of 8 to 10 | |
| Pain intensity ‐ Ordinal scale pain faces 4 to 5, 24 hrs after randomisation | 1 (119) | RR 0.69, 95% CI 0.54 to 0.87, significantly fewer women in the immersion group had pain faces 4 to 5 on pain scale | |
| ` | Satisfaction with pain relief | Outcome not reported | |
| Sense of control in labour | Outcome not reported | ||
| Satisfaction with childbirth experience | Outcome not reported | ||
| Effect on mother/baby interaction | Outcome not reported | ||
| Breastfeeding (not breastfeeding after six weeks post delivery) | 2 (363) | RR 1.17, 95% CI 0.64 to 2.15, no evidence of a significant difference between groups | |
| Assisted vaginal birth | 7 (2628) | RR 0.86, 95% CI 0.71 to 1.05, no evidence of a significant difference between groups | |
| Caesarean section | 8 (2712) | RR 1.21, 95% CI 0.87 to 1.68, no evidence of a significant difference between groups | |
| Adverse effects for women (postpartum haemorrhage) | 1 (274) | RR 1.58, 95% CI 0.80 to 3.13, no evidence of a significant difference between groups | |
| Adverse effects for women (blood loss ‐ mean blood loss ml) | 2 (153) | MD ‐14.33. 95% CI ‐63.03 to 34.37, no evidence of a significant difference between groups | |
| Adverse effects for women (perineal trauma ‐ episiotomy) | 5 (1272) | RR 0.93, 95% CI 0.80 to 1.08, no evidence of a significant difference between groups | |
| Adverse effects for women (perineal trauma – second‐degree tear) | 5 (1286) | RR 0.94, 95% CI 0.74 to 1.20, no evidence of a significant difference between groups | |
| Adverse effects for women (perineal trauma – third or fourth degree tear) | 5 (2401) | RR 1.37, 95% CI 0.86 to 2.17, no evidence of a significant difference between groups | |
| Adverse effects for women (systolic blood pressure) | 1 (120) | MD ‐7.20, 95% CI ‐13.12 to ‐1.28, mean systolic blood pressure significantly lower in the immersion group | |
| Adverse effects for women (diastolic blood pressure) | 1 (120) | MD ‐10.20, 95% CI ‐13.70 to ‐6.70, mean diastolic blood pressure significantly lower in the immersion group | |
| Adverse effects for women (arterial blood pressure) | 1 (120) | MD ‐10.50, 95% CI ‐14.68 to ‐6.32, mean arterial blood pressure significantly lower in the immersion group | |
| Adverse effects for women (maternal infection – perineal, systemic, uterine or increase in temperature) | 5 (1295) | RR 0.99, 95% CI 0.50 to 1.96, no significant difference between groups | |
| Adverse effects for women (postpartum depression ‐ score of more than 11 on the Edinburgh Postnatal Depression Scale EPDS) | 2 (370) | RR 1.38, 95% CI 0.85 to 2.24, no significant difference between groups in the incidence of postpartum depression | |
| Adverse effects for infants (presence of meconium stained liquor) | 5 (1260) | RR 0.95, 95% CI 0.76 to 1.19, no evidence of a significant difference between groups for meconium staining | |
| Adverse effects for infants (abnormal fetal heart rate patterns) | 3 (487) | RR 0.75, 95% CI 0.34 to 1.67, (random effects; heterogeneity: I2 = 57%, Tau2 = 0.22, Chi2 test for heterogeneity P = 0.13), no evidence of a significant difference |
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| Adverse effects for infants (umbilical artery pH less than 7.20) | 1 (110) | RR 5.18, 95% CI 0.25 to 105.51, no evidence of a significant difference between groups | |
| Adverse effects for infants (temperature greater than 37.8 degrees C as an indicator for infection) | 1 (274) | RR 1.00, 95% CI 0.06 to 15.83, no evidence of a significant difference between groups | |
| Adverse effects for infants (neonatal infection) | 5 (1295) | RR 2.00, 95% CI 0.50 to 7.94, no evidence of a significant difference between groups | |
| Admission to neonatal intensive care unit | 3 (1571) | RR 1.06, 95% CI 0.71 to 1.57, no evidence of a significant difference between groups | |
| Apgar score less than seven at five minutes | 5 (1834) | RR 1.58, 95% CI 0.63 to 3.93, no evidence of a significant difference between groups | |
| Poor infant outcomes at long‐term follow‐up | Outcome not reported | ||
| Cost | Outcome not reported | ||
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4.1. Immersion versus no immersion in the second stage of labour (3 studies, 286 women) |
Outcome | No. of studies (no. women) | Results |
| Pain intensity – number of women reporting moderate to severe pain on an ordinal scale | 1 (117) | RR 1.06, 95% CI 0.73 to 1.53, no significant difference between groups in women experiencing moderate to severe pain | |
| Satisfaction with pain relief | Outcome not reported | ||
| Sense of control in labour | Outcome not reported | ||
| Satisfaction with childbirth experience (reported that they did not cope satisfactorily with their pushing efforts) | 1 (117) | RR 0.24, 95% CI 0.07 to 0.80, significantly fewer women in the immersion group reported low satisfaction | |
| Satisfaction with childbirth experience (satisfaction with labour and birth on scale of 0‐6 where 0 is not at all satisfied) | 1 (60) | MD 0.03, 95% CI ‐0.64 to 0.70, no significant difference between mean satisfaction scores | |
| Effect (negative) on mother/baby interaction | Outcome not reported | ||
| Breastfeeding | 1 (60) | RR 0.86, 95% CI 0.69 to 1.08, no evidence of a significant difference between groups | |
| Assisted vaginal birth | 2 (180) | RR 0.73, 95% CI 0.21 to 2.54, no evidence of a significant difference between groups | |
| Caesarean section | 2 (180) | RR 0.33, 95% CI 0.07 to 1.52, no evidence of a significant difference between groups | |
| Adverse effects for women (perineal trauma ‐ episiotomy) | 2 (179) | RR 0.75, 95% CI 0.35 to 1.60, no evidence of a significant difference between groups | |
| Adverse effects for women (perineal trauma – second‐degree tear) | 2 (179) | RR 1.21, 95% CI 0.65 to 2.24, no evidence of a significant difference between groups | |
| Adverse effects for women (perineal trauma – third or fourth degree tear) | 1 (60) | RR 1.54, 95% CI 0.07 to 36.11, no evidence of a significant difference between groups | |
| Adverse effects for women (postpartum haemorrhage more than 500 ml) | 1 (120) | RR 0.14, 95% CI 0.01 to 2.71, no evidence of a significant difference between groups | |
| Adverse effects for women (maternal temperature) | 1 (60) | MD 0.20, 95% CI ‐0.18 to 0.58, no evidence of a significant difference in mean temperature between groups | |
| Adverse effects for infants (presence of meconium stained liquor) | 2 (180) | RR 1.32, 95% CI 0.63 to 2.80, no evidence of a significant difference between groups | |
| Adverse effects for infants (umbilical artery pH less than 7.20) | 1 (116) | RR 0.89, 95% CI 0.45 to 1.75, no evidence of a significant difference between groups | |
| Adverse effects for infants (antibiotics given to neonate) | 1 (60) | RR 1.50, 95% CI 0.17 to 13.52, no evidence of a significant difference between groups | |
| Adverse effects for infants (positive neonatal swab of ear, mouth or umbilicus) | 1 (154) | RR 1.89, 95% CI 0.90 to 3.96, no evidence of a significant difference between groups | |
| Admission to special care baby unit/neonatal intensive care unit | 2 (180) | RR 0.79, 95% CI 0.25 to 2.49, no evidence of a significant difference between groups | |
| Apgar score less than seven at five minutes | 1 (119) | RR 4.92, 95% CI 0.24 to 100.31, no evidence of a significant difference between groups | |
| Poor infant outcomes at long‐term follow‐up | Outcome not reported | ||
| Cost | Outcome not reported | ||
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4.2. Early versus late immersion during the first stage of labour (1 study, 200 women) |
Outcome | No. of studies (no. women) | Results |
| Pain intensity | Outcome not reported | ||
| Satisfaction with pain relief | Outcome not reported | ||
| Sense of control in labour | Outcome not reported | ||
| Satisfaction with childbirth experience | Outcome not reported | ||
| Effect (negative) on mother/baby interaction | Outcome not reported | ||
| Breastfeeding | Outcome not reported | ||
| Assisted vaginal birth | Outcome not reported | ||
| Caesarean section | Outcome not reported | ||
| Adverse effects for women | Outcome not reported | ||
| Adverse effects for infants (Neonatal infection) | 1 (200) | RR 3.00, 95% CI 0.12 to 72.77, no evidence of a significant difference between groups | |
| Admission to special care baby unit/neonatal intensive care unit | Not estimable | ||
| Apgar score less than seven at one minute | 1 (200) | Not estimable | |
| Poor infant outcomes at long‐term follow‐up | Outcome not reported | ||
| Cost | Outcome not reported | ||
I2 values reported in table only when random effects analysis has been carried out due to substantial heterogeneity indicated by an I2 value greater than 30% CI: confidence interval; MD: mean difference; RR: risk ratio; VAS: visual analogue scale