Parturition at term: induction, second and third stages of labor, and optimal management of life-threatening complications-hemorrhage, infection, and uterine rupture.

Childbirth is a defining moment in anyone's life, and it occurs 140 million times per year. Largely a physiologic process, parturition does come with risks; one mother dies every two minutes. These deaths occur mostly among healthy women, and many are considered preventable. For each death, 20 to 30 mothers experience complications that compromise their short- and long-term health. The risk of birth extends to the newborn, and, in 2020, 2.4 million neonates died, 25% in the first day of life. Hence, intrapartum care is an important priority for society. The American Journal of Obstetrics & Gynecology has devoted two special Supplements in 2023 and 2024 to the clinical aspects of labor at term. This article describes the content of the Supplements and highlights new developments in the induction of labor (a comparison of methods, definition of failed induction, new pharmacologic agents), management of the second stage, the value of intrapartum sonography, new concepts on soft tissue dystocia, optimal care during the third stage, and common complications that account for maternal death, such as infection, hemorrhage, and uterine rupture. All articles are available to subscribers and non-subscribers and have supporting video content to enhance dissemination and improve intrapartum care. Our hope is that no mother suffers because of lack of information.

Water birth: a systematic review and meta-analysis of maternal and neonatal outcomes.

OBJECTIVE: This systematic review and meta-analysis aimed to conduct a thorough and contemporary assessment of maternal and neonatal outcomes associated with water birth in comparison with land-based birth. DATA SOURCES: We conducted a comprehensive search of PubMed, EMBASE, CINAHL, and gray literature sources, from inception to February 28, 2023. STUDY ELIGIBILITY CRITERIA: We included randomized and nonrandomized studies that assessed maternal and neonatal outcomes in patients who delivered either conventionally or while submerged in water. METHODS: Pooled unadjusted odds ratios with 95% confidence intervals were calculated using a random-effects model (restricted maximum likelihood method). We assessed the 95% prediction intervals to estimate the likely range of future study results. To evaluate the robustness of the results, we calculated fragility indices. Maternal infection was designated as the primary outcome, whereas postpartum hemorrhage, perineal lacerations, obstetrical anal sphincter injury, umbilical cord avulsion, low Apgar scores, neonatal aspiration requiring resuscitation, neonatal infection, neonatal mortality within 30 days of birth, and neonatal intensive care unit admission were considered secondary outcomes. RESULTS: Of the 20,642 articles identified, 52 were included in the meta-analyses. Based on data from observational studies, water birth was not associated with increased probability of maternal infection compared with land birth (10 articles, 113,395 pregnancies; odds ratio, 0.93; 95% confidence interval, 0.76-1.14). Patients undergoing water birth had decreased odds of postpartum hemorrhage (21 articles, 149,732 pregnancies; odds ratio, 0.80; 95% confidence interval, 0.68-0.94). Neonates delivered while submerged in water had increased odds of cord avulsion (10 articles, 91,504 pregnancies; odds ratio, 1.75; 95% confidence interval, 1.38-2.24) and decreased odds of low Apgar scores (21 articles, 165,917 pregnancies; odds ratio, 0.69; 95% confidence interval, 0.58-0.82), neonatal infection (15 articles, 53,635 pregnancies; odds ratio, 0.64; 95% confidence interval, 0.42-0.97), neonatal aspiration requiring resuscitation (19 articles, 181,001 pregnancies; odds ratio, 0.60; 95% confidence interval, 0.43-0.84), and neonatal intensive care unit admission (30 articles, 287,698 pregnancies; odds ratio, 0.56; 95% confidence interval, 0.45-0.70). CONCLUSION: When compared with land birth, water birth does not appear to increase the risk of most maternal and neonatal complications. Like any other delivery method, water birth has its unique considerations and potential risks, which health care providers and expectant parents should evaluate thoroughly. However, with proper precautions in place, water birth can be a reasonable choice for mothers and newborns, in facilities equipped to conduct water births safely.

Birth mode is associated with development of atopic dermatitis in infancy and early childhood.

Background: Birth by caesarean section (CS) is associated with development of allergic diseases, but its role in the development of atopic dermatitis (AD) is less convincing. Objective: Our primary aim was to determine if birth mode was associated with AD in 3-year-olds and secondarily to determine if birth mode was associated with early onset and/or persistent AD in the first 3 years of life. Methods: We included 2129 mother-child pairs from the Scandinavian population-based prospective PreventADALL cohort with information on birth mode including vaginal birth, either traditional (81.3%) or in water (4.0%), and CS before (6.3%) and after (8.5%) onset of labor. We defined early onset AD as eczema at 3 months and AD diagnosis by 3 years of age. Persistent AD was defined as eczema both in the first year and at 3 years of age, together with an AD diagnosis by 3 years of age. Results: AD was diagnosed at 3, 6, 12, 24, and/or 36 months in 531 children (25%). Compared to vaginal delivery, CS was overall associated with increased odds of AD by 3 years of age, with adjusted odds ratio (95% confidence interval) of 1.33 (1.02-1.74), and higher odds of early onset AD (1.63, 1.06-2.48). The highest odds for early onset AD were observed in infants born by CS after onset of labor (1.83, 1.09-3.07). Birth mode was not associated with persistent AD. Conclusion: CS was associated with increased odds of AD by 3 years of age, particularly in infants presenting with eczema at 3 months of age.

Understanding the barriers and facilitators related to birthing pool use from organisational and multi-professional perspectives: a mixed-methods systematic review.

AIMS: To identify and synthesize the evidence regarding the facilitators and barriers relating to birthing pool use from organizational and multi-professional perspectives. DESIGN: A systematic integrated mixed methods review was conducted. DATA SOURCES: MEDLINE, CINAHL, PsychINFO, EMCARE, PROQUEST and Web of Science databases were searched in April 2021, March 2022 and April 2024. We cross-referenced with Google Scholar and undertook reference list searches. REVIEW METHODS: Data were extracted from studies meeting the inclusion criteria. Barriers and facilitators to birthing pool use were mapped and integrated into descriptive statements further synthesized to develop overarching themes. RESULTS: Thirty seven articles (29 studies) were included-quantitative (12), qualitative (8), mixed methods (7), and audits (2), from 12 countries. These included the views of 9,082 multi-professionals (midwives, nurses, obstetricians, neonatologists, students, physicians, maternity support workers, doulas and childbirth educators). Additionally, 285 institutional policies or guidelines were included over 9 papers and 1 economic evaluation. Five themes were generated: The paradox of prescriptiveness, The experienced but elusive practitioner, Advocacy and tensions, Trust or Trepidation and It's your choice, but only if it is a choice. These revealed when personal, contextual, and infrastructural factors were aligned and directed towards the support of birth pool use, birthing pool use was a genuine option. Conversely, the more barriers that women and midwives experienced, the less likely it was a viable option, reducing choice and access to safe analgesia. CONCLUSION: The findings demonstrated a paradoxical reality of water immersion with each of the five themes detailing how the "swing" within these factors directly affected whether birthing pool use was facilitated or inhibited.

Alternate Birth Strategies.

Community birth is defined as birth that occurs outside the hospital setting. Birthing in a birth center can be safe for certain patient populations. Home birth can also be safe in well-selected patient with a well-established transfer infrastructure should an emergency occur. Unfortunately, many areas of the United States and the world do not have this infrastructure, limiting access to safe community birth. Immersion during labor has been associated with decreased need for epidural and pain medication. Delivery should not occur in water due to concerns for infection and cord avulsion. Umbilical cord non-severance (also called lotus birth) and placentophagy should be counseled against due to well-documented risks without clear benefit. Birth plans and options should be regularly discussed during pregnancy visits.

Content Analysis of Water Birth Policies With Implications for Practice and Research.

OBJECTIVE: To identify areas of agreement and variation in clinical guidance documents (protocols, policies, or guidelines) that direct water birth care. DESIGN: Qualitative descriptive. SETTING: The clinical guidance documents studied covered water birth in home and hospital settings. SAMPLE: The sample included 22 water birth guidance documents in English from six countries. The documents were obtained by request and resulting snowball sampling. MEASUREMENTS: The framework method was adapted as an analytic tool, and a structured matrix output was used to organize and support the method of qualitative content analysis using a general inductive approach. Areas of general agreement and variations in practice guidelines for water birth were identified. RESULTS: Criteria for a term, singleton, and cephalic presentation with reassuring maternal and fetal status were the most consistent for inclusion. The reliance on "low-risk" status was strongly present but without a uniform definition. A history of previous cesarean birth, body mass index, use of opioid pain medication, adequate labor progress, and vaginal bleeding were found to vary in directed care, and scarce supporting evidence was offered. Meconium-stained fluid variably excluded water birth in most documents, but this was not supported by evidence. The inconsistent findings from this study are cohesive in the evidence they provide for needed research in areas that affect access to water birth. The findings also provide nurses and birth providers with evidence-based guidelines for water birth care. CONCLUSION: There was variation across guidance documents, demonstrating that water immersion is a flexible intervention that can be implemented in different settings and locations while following individual facility protocols for processes for care. An identified area of concern comes from examples of overly restrictive policies for water birth based on opinion or perceived risk rather than evidence from research.

Spiritual Experiences of Portuguese Women Who had a Water Birth.

This study aimed to understand the significance of spirituality to Portuguese women who had a water birth. In-depth interviews, using a semi-structured questionnaire, were conducted with 24 women who experienced water birth at the hospital or home. Results were analyzed from a narrative interpretation perspective. Three spirituality-related categories emerged: (1) Beliefs and connections with the body; (2) Spirituality: integration of being a woman and transformation during birth; and (3) Spirituality as wisdom, intuition, or the sixth sense. Spirituality was perceived in women's faith and beliefs in a superior being that helped them manage the unpredictability and uncontrollability of giving birth.

Perception and knowledge of Saudi women about water birth: A cross-sectional study.

Background: Water birth has been considered an efficient non-pharmacological modality with numerous maternal and neonatal benefits as well as rare complications. Perception and knowledge about water birth can affect women's decisions in the future. Few available studies addressed this area in Saudi Arabia. Thus, the current research fills this gap and contributes to further understanding this phenomenon. Objective: This study aimed to assess the perception and knowledge of Saudi women about water birth. Methods: A cross-sectional study was employed among 388 Saudi women conveniently enrolled for the study. An online questionnaire that included four sections: sociodemographic characteristics, obstetrical history, perception, and knowledge of water birth, was used for data collection. Descriptive statistics (frequencies, percentages, means, and standard deviations) and inferential statistics (Chi-Square, Fisher Exact, and t-tests) were used for data analysis. Results: The participants' mean age was 34.91 ± 8.851, with 83.2% of them highly educated. The mean number of deliveries was 3.36 ± 2.167, with 60% having no history of abortion. Less than half of the participants (40.2%) preferred to have a water delivery. Of the total participants, 96.4% had a fair knowledge level, and 3.6% had a good knowledge of water delivery. A significant relationship was found between age, educational course, and the knowledge of the participants about water delivery (p <0.05). Conclusion: Most Saudi women had a fair knowledge of water birth; however, they wanted more information on it. It is recommended that midwives and nurses broaden their understanding of water birth and enhance its practice in order to educate and inspire women to make informed decisions about all available childbirth delivery methods, including water birth.

Maternal and neonatal outcomes following waterbirth: a cohort study of 17 530 waterbirths and 17 530 propensity score-matched land births.

OBJECTIVE: Investigate maternal and neonatal outcomes following waterbirth. DESIGN: Retrospective cohort study, with propensity score matching to address confounding. SETTING: Community births, United States. SAMPLE: Medical records-based registry data from low-risk births were used to create waterbirth and land birth groups (n = 17 530 each), propensity score-matched on >80 demographic and pregnancy risk covariables. METHODS: Logistic regression models compared outcomes between the matched waterbirth and land birth groups. MAIN OUTCOME MEASURES: Maternal: immediate postpartum transfer to a hospital, any genital tract trauma, severe (3rd/4th degree) trauma, haemorrhage >1000 mL, diagnosed haemorrhage regardless of estimated blood loss, uterine infection, uterine infection requiring hospitalisation, any hospitalisation in the first 6 weeks. Neonatal: umbilical cord avulsion; immediate neonatal transfer to a hospital; respiratory distress syndrome; any hospitalisation, neonatal intensive care unit (NICU) admission, or neonatal infection in the first 6 weeks; and neonatal death. RESULTS: Waterbirth was associated with improved or no difference in outcomes for most measures, including neonatal death (adjusted odds ratio [aOR] 0.56, 95% CI 0.31-1.0), and maternal or neonatal hospitalisation in the first 6 weeks (aOR 0.87, 95% CI 0.81-0.92 and aOR 0.95, 95% CI 0.90-0.99, respectively). Increased morbidity in the waterbirth group was observed for two outcomes only: uterine infection (aOR 1.25, 95% CI 1.05-1.48) (but not hospitalisation for infection) and umbilical cord avulsion (aOR 1.57, 95% CI 1.37-1.82). Our results are concordant with other studies: waterbirth is neither as harmful as some current guidelines suggest, nor as benign as some proponents claim. TWEETABLE ABSTRACT: New study demonstrates #waterbirth is neither as harmful as some current guidelines suggest, nor as benign as some proponents claim. @TheUpliftLab @BovbjergMarit @31415926abc @NICHD_NIH.

In water or on land? Evaluation of perinatal and neonatal outcomes of water births in low-risk women.

OBJECTIVE: Evaluate perinatal and neonatal outcomes comparing a water birth to regular childbirth in low-risk women. File and methods: Retrospective analysis of a set of childbirths that took place over a given period of time in the hospital and health center of Havířov. We compared a set of low-risk women that had given a water birth to a selected control group of low-risk women that had given regular childbirth. We evaluated statistical comparability, as well as perinatal and neonatal outcomes in both sets. RESULTS: From 1. 1. 2020 to 28. 2. 2021, 1,083 women gave birth in the delivery department of Havířov hospital; from this set 122 were water births (11.3%). In our study, we only included 101 water deliveries (we designed our study to monitor low-risk births in order to be able to statistically correlate our findings; 21 water deliveries were excluded from our study due to perinatal risk factors - gestational diabetes and induced deliveries). We selected 60 low-risk women for our control group. Both sets of women were compared and we ruled out any statistically significant differences in age, education, body mass index, number of births given, gestation week at time of labor, number of smokers, premature rupture of membranes, women with previous history of one cesarean section, becoming pregnant by in vitro fertilization, presence of streptokoka skupiny B, and fetal weight. Water birth does not affect the Apgar score, neonatal adaptation to extra-uterine life, umbilical blood pH decrease, complications of infection, need of intensive care, and neonatal mortality. In the water birth set, we found increased occurrence of non-infectious conjunctivitis, treatable by regular eye drops without antibio-tics. We have not observed the effect of water birth on duration of the first and second stage of labor, total amount of uterotonics used, blood loss determined by the obstetrician, and uterine hypotonia. In the water birth group, we observed a prolonged third stage of delivery, lesser need for pharmacological stimulation (augmentation) of labor, notably lower use of analgesics, lower occurrence of birth injuries, shorter in-patient time, and more frequent bonding. CONCLUSIONS: We discovered that water birth does not increase the risk for mother and neonate in low-risk women. Despite initial concerns, our outcomes and mother satisfaction have clearly shown that water births are not only a temporary whim, but probably a new integral part of our obstetric care.

[Basic hygiene measures in the delivery room-also during a pandemic]. / Basis-Hygienemaßnahmen im Kreißsaal ­ auch in Zeiten einer Pandemie.

BACKGROUND: The German Infection Protection Act calls for effective measures to be implemented in clinics to avoid nosocomial infections. The corona pandemic once again demonstrates the importance of adequate hygiene measures in avoiding infections. OBJECTIVES: Compilation of common basic hygiene measures for clinical obstetrics. METHODS: Discussion of relevant German guidelines relating to the work in the delivery room. Development of recommendations for hygienically correct childbirth care. RESULTS: Recommendations for surface disinfection refer to predefined risk-categories in the delivery unit. In cooperation with hospital hygiene, the frequency of cleaning and disinfection must be specified in the facility's internal hygiene plans. To avoid a selection of disinfectant-tolerant germs, it is essential to observe the spectrum of activity and exposure time of each disinfectant. Hand disinfection is the single most effective measure to prevent nosocomial infections. The challenge here is the consistent implementation of the generally known indications for hand disinfection in everyday life. For the hygienically correct management of water birth and maintenance of the bathtub, standards should be developed in every delivery room, the effectiveness of which must be regularly monitored. In a pandemic, there are additional hygiene rules, tailored to the particular pathogen. CONCLUSIONS: Although there is no lack of knowledge in the form of guidelines and recommendations, the implementation of basic hygiene measures in everyday life in the delivery room requires perseverance and commitment.

Feature Article-Continuing Education Module-International Water-Birth Practices With Recommendations During a Global Pandemic.

The number of hospitals globally that offer water birth has increased exponentially during the past 10 years. This article examines some of the reasons for this increase as well as the objections to water birth by The American College of Obstetricians and Gynecologists, raised in their 2014 and 2016 opinion statements. The amount of research has also increased as more hospitals are keeping track of their data and publishing both prospective studies and retrospective analyses. The effects of water birth on the neonate are discussed through three meta-analyses from 2015, 2016, and 2018. The challenges and recommendations on continuing the use of water during labor and birth as a nonpharmacologic comfort measure even during a global pandemic are highlighted and supported by the best available evidence.

'They follow the wants and needs of an institution': Midwives' views of water immersion.

BACKGROUND: A midwife's ability to fully support women's autonomy and self-determination with respect to midwifery care is often challenging. This is particularly true of water immersion for labour and birth. However, the woman's agency over what happens to her body and that of her unborn baby should be key considerations for maternity care provision. OBJECTIVES: A three phased mixed-methods study was undertaken to examine how water immersion policies and guidelines are informed. Phase three of this study captured the knowledge and experiences of Australian midwives, their support for water immersion and their experiences of using policies and guidelines to inform and facilitate the practice. METHODS: Critical, post structural, interpretive interactionism was used to examine more than 300 responses to three open-ended questions included in a survey of 233 midwives. Comment data were analysed to provide further insight, context and meaning to previously reported results. FINDINGS: Findings demonstrated a complex, multidimensional interplay of factors that impacted on both the midwife's ability to offer and the woman's decision to use water immersion under the themes 'the reality of the system', 'the authoritative 'others'' and 'the pseudo decision-makers'. Multiple scaffolded levels were identified, each influenced by the wider macro-socio-political landscape of Australian midwifery care. CONCLUSIONS: The insight gained from examining midwives' views and opinions of water for labour and birth, has aided in contextualising previously reported results. Such insight highlights the importance of qualitative research in challenging the status quo and working towards woman-centred practice and policy.

Factors influencing water immersion during labour: qualitative case studies of six maternity units in the United Kingdom.

BACKGROUND: Water immersion during labour can provide benefits including reduced need for regional analgesia and a shorter labour. However, in the United Kingdom a minority of women use a pool for labour or birth, with pool use particularly uncommon in obstetric-led settings. Maternity unit culture has been identified as an important influence on pool use, but this and other possible factors have not been explored in-depth. Therefore, the aim of this study was to identify factors influencing pool use through qualitative case studies of three obstetric units and three midwifery units in the UK. METHODS: Case study units with a range of waterbirth rates and representing geographically diverse locations were selected. Data collection methods comprised semi-structured interviews, collation of service documentation and public-facing information, and observations of the unit environment. There were 111 interview participants, purposively sampled to include midwives, postnatal women, obstetricians, neonatologists, midwifery support workers and doulas. A framework approach was used to analyse all case study data. RESULTS: Obstetric unit culture was a key factor restricting pool use. We found substantial differences between obstetric and midwifery units in terms of equipment and resources, staff attitudes and confidence, senior staff support and women's awareness of water immersion. Generic factors influencing use of pools across all units included limited access to waterbirth training, sociodemographic differences in desire for pool use and issues using waterproof fetal monitoring equipment. CONCLUSIONS: Case study findings provide new insights into the influence of maternity unit culture on waterbirth rates. Access to pool use could be improved through midwives based in obstetric units having more experience of waterbirth, providing obstetricians and neonatologists with information on the practicalities of pool use and improving accessibility of antenatal information. In terms of resources, recommendations include increasing pool provision, ensuring birth room allocation maximises the use of unit resources, and providing pool room environments that are acceptable to midwives.

Is It Just Water Under the Bridge? An Eight-Day-Old With Late-Onset Group B Streptococcal Infection After Water Birth.

Group B Streptococcus (Streptococcus agalactiae or GBS) infections are known as a leading cause of morbidity and mortality in the neonatal population. The role of water birth in colonizing and transmitting GBS between mother and infant is unclear. We present a case of an exclusively breastfed full-term infant, born via water birth, to a GBS-negative woman who developed GBS mastitis. The infant presented with severe, late-onset GBS meningitis/septic shock and subsequently developed fatal necrotizing enterocolitis. Literature regarding the potential role of water birth in GBS transmission is reviewed.

Outcomes of Waterbirth in a US Hospital-Based Midwifery Practice: A Retrospective Cohort Study of Water Immersion During Labor and Birth.

INTRODUCTION: Although the safety of water immersion during labor is largely supported by evidence from research, the risks to women and neonates during waterbirth are not well established. The purpose of this study was to generate evidence regarding maternal and neonatal outcomes related to water immersion in labor and during birth. METHODS: A retrospective cohort study included a convenience sample of women receiving prenatal care at a nurse-midwifery practice. Participants were categorized into 3 groups: 1) waterbirth, 2) water labor, or 3) neither. Participant characteristics, maternal outcomes, and newborn outcomes were collected at time of birth and health record abstraction. At the 6-week postpartum visit, another maternal outcome, satisfaction with birth, was measured using the Care in Obstetrics: Measure for Testing Satisfaction (COMFORTS) scale. Analysis included effect size, descriptive statistics (sample characteristics), and maternal and neonatal group differences (analysis of variance and chi-square) with a significance level of P < .05. RESULTS: Women in the waterbirth (n = 58), water labor (n = 61), and neither (n = 111) groups were primarily white, married, and college educated and did not differ by age or education. Women in the waterbirth group were more likely to be multiparous. Nulliparous women who had a waterbirth had a significantly shorter second stage of labor than nulliparous women who did not have a waterbirth (P = .03). The most commonly cited reasons for discontinuation of hydrotherapy were maternal choice (42.6%) and need for pain medication (29.5%). Significantly more women in the waterbirth group experienced a postpartum hemorrhage, compared with water labor or neither (n = 5, n = 3, n = 1, respectively; P = .045); there was no difference in related clinical measures. Neonatal outcomes were not significantly different. Maternal satisfaction was high across all groups. DISCUSSION: The results of this study suggest that waterbirth, attended by qualified intrapartum care providers in hospital settings in the United States, is a reasonable option for low-risk women and their neonates.

Water Birth and Perinatal Outcomes in British Columbia: A Retrospective Cohort Study.

OBJECTIVE: This study aimed to quantify adverse neonatal outcomes in a cohort of registered midwife (RM)-attended conventional and water births in British Columbia. METHODS: The study included all term singleton births in British Columbia between January 1, 2005 and March 31, 2016 attended by RMs. Births were allocated to a conventional birth cohort or a water birth cohort according to where the actual birth of the neonate took place. The primary outcome was a composite adverse neonatal outcome (Apgar <7 at 5 minutes, resuscitation need, neonatal intensive care unit admission). Secondary outcomes included individual components of the primary outcome, maternal length of labour, and degree of perineal laceration (Canadian Task Force Classification Level II-2). RESULTS: The population included 25 798 births. Of these, 23 201 were conventional, and 2567 were water births. The rate of the composite adverse neonatal outcome was not higher in water births compared with conventional births (hospital conventional, 5.0%; hospital water, 4.2%; home conventional, 3.4%; and home water, 2.9%). Rates of individual components of the composite adverse neonatal score were not greater in the water birth cohort. Maternal outcomes included statistically shorter labours in the water birth cohort and no difference between the cohorts in incidence of third- and fourth-degree lacerations. CONCLUSION: Water births attended by RMs in British Columbia are not associated with higher rates of adverse neonatal outcomes than conventional births attended by midwives.

Factors influencing the use of birth pools in the United Kingdom: Perspectives of women, midwives and medical staff.

OBJECTIVE: To identify factors influencing the use of birth pools. DESIGN: Online discussion groups and semi-structured interviews, analysed thematically. SETTING: United Kingdom. PARTICIPANTS: 85 women and 21 midwives took part in online discussion groups; 14 medical staff participated in interviews. FINDINGS: Factors influencing the use of birth pools were grouped into three overarching categories: resources, unit culture and guidelines, and staff endorsement. Resources encompassed pool availability, efficiency of pool use and availability of waterproof cardiotocograph equipment. Unit culture and guidelines related to eligibility criteria for pool use, medicalisation of birth and differences between midwifery-led and obstetric-led care. Staff endorsement encompassed attitudes towards pool use. KEY CONCLUSIONS: Accessibility of birth pools was often limited by eligibility criteria. While midwifery-led units were generally supportive of pool use, obstetric-led units were described as an over-medicalised environment in which pool use was restricted and relied on maternal request. IMPLICATIONS FOR PRACTICE: Midwives can improve women's access to birth pools by providing information antenatally and proactively offering this as an option in labour. Maternity units should work to implement evidence-based guidelines on pool use, increase pool availability (even where there appears to be low demand), and enhance awareness amongst medical staff of the benefits of water immersion.

Water Birth Maternal and Neonatal Outcomes Among Midwifery Clients in Alberta, Canada, from 2014 to 2017: A Retrospective Study.

OBJECTIVES: This study sought to evaluate retrospectively the maternal and neonatal outcomes of water births (WBs) managed by Registered Midwives in Alberta compared with traditional or "land" vaginal birth outcomes for clinical evidence or knowledge and to assist in health care management planning. METHODS: This study was a retrospective cohort comparison of maternal and neonatal outcomes of WB (1716) and traditional or land birth (non-WB) (21 320) from selected low-risk maternal cohorts with spontaneous onset of labour and vaginal delivery in Alberta (2014-2017) using Alberta Perinatal Health Program data sets. Anonymized client and patient records linked the Alberta Perinatal Health Program data with inpatient Discharge Abstract Database for newborn and/or maternal personal health number (PHN/ULI) analyzed using SPSS 19.0 software (IBM Corp., Armonk, NY) (Canadian Task Force Classification II-2). RESULTS: The WB group had fewer and less severe perineal lacerations despite increased macrosomia. The non-WB group had increased maternal factors (age <20 years, third- to fourth-degree perineal tears, excessive blood loss) and neonatal factors (Apgar scores <7 at 5 minutes and neonatal intensive care unit admission). No significant difference was identified between the birth groups for maternal age >35 years, primiparous status, maternal fever, maternal puerperal infection, maternal intensive care unit admission, low birth weight, neonatal resuscitation, and neonatal intensive care unit admission <28 days of life. CONCLUSIONS: A low-risk maternal cohort of WBs (1716) managed by midwives had equivalent or improved neonatal outcomes compared with a low-risk maternal cohort of land or traditional births (21 320) managed by midwives and other maternity providers.