Vital Views

Joe Gaccione 0:07
Hello, and welcome to Vital Views, UNLV School of Nursing podcast. I'm Joe Gaccione, Communications Director for the School of Nursing. Is water immersion an effective way to allow pregnant women to give birth? That's the overall takeaway from a new National Review involving one of UNLV Nursing’s faculty. This review looked at 36 studies involving at least 150,000 women to see the potential positive outcomes of waterbirths. This research even gained enough attention to be featured on a recent broadcast of Good Morning America, as well as multiple health related publications across the country. Joining us today to talk about water immersion and this research is Dr. Jennifer Vanderlaan, assistant professor at UNLV School of Nursing. She's also a certified nurse midwife and family nurse practitioner, and one of the coauthors of this new review. Dr. Vanderlaan, thanks for stopping in.

Jennifer Vanderlaan 0:59
Thank you for having me.

Joe Gaccione 1:00
Before we get to the study, can we just talk more about water immersion in general? What is it? How does it work during labor and delivery?

Jennifer Vanderlaan 1:08
Sure. Water immersion is the use of a large tub of warm water. So, you could think of it like sitting in a hot tub except the water is kept at body temperature. We use water immersion during labor because it's an effective way to reduce the pain that's associated with contractions. And at the same time, being in the water increases a person's ability to move around in response to their contractions, so they can change positions easier. When women are offered the ability to be in a tub, it reduces the use of epidurals and other pharmacologic pain relief tools. In studies, people who use water immersion have reported that they get other benefits as well. They tell us that they have less fear, they have a better ability to relax, and there's an increased sense of control. When people want to use water immersion. The usual process is to undergo your initial assessments, all the things that the nurse and midwife will do to verify that you are in labor and both mom and baby are healthy. Once we know everything is progressing normally, the individual can start using the tub. When I say using the tub, though, I don't mean they have to stay in the tub the whole time. They, the person can get in and out of the water based on what is most comfortable at that moment. So, it might feel good to be in the water for a while and then the person might want to walk around for a while and come back to the tub later. Oftentimes people will get out of the tub to go to the bathroom and decide they want to stay in an upright position. So they do something else for a while before getting back in the tub. Eventually, the act of labor turns into the pushing stage of labor. Some people do like to stay in the water for the pushing part, because it continues to offer pain relief and increased mobility. In an earlier study that I did, I found out that just over half of the people who use the tub during labor, stay in the tubs for pushing and actually give birth in the tubs. And when birth happens in the tub, we call that waterbirth.

Joe Gaccione 3:03
I imagine for parents listening to this, maybe the first reaction is going to be what happens to the baby when the baby comes out? Is it totally submerged in water, it, does the nurse midwife or another health professional immediately grab it, how does that work?

Jennifer Vanderlaan 3:16
The baby does come out totally submerged in the water. In fact, that's important because if the baby isn't completely underwater, you could initiate, if the baby touches the air, you might start breathing. So the baby is born completely underwater. And then once the full body is out, the midwife will bring the baby up out of the water and put the, usually put the baby on the mom's chest and the baby doesn't go back onto the water again.

Joe Gaccione 3:40
And how common are waterbirths in the US?

Jennifer Vanderlaan 3:43
Not very common. We don't have good statistics on it, but I did check. We included data about it in a survey that we did for nurse midwives and I found that about 26% of practices with midwives will offer waterbirth but about half of those are practices that only do home or birth center birth. So it's not very common in hospitals in the United States.

Joe Gaccione 4:08
Is that part of a debate about traditional labor versus natural birth and what's right and what's wrong? Is that part of a bigger issue or is it just preference, most people don't choose to have it?

Jennifer Vanderlaan 4:19
I think it has to do actually with it's just not available. I think, I think a lot of people enjoy being in a hot tub. They think it's comfortable to be in water and they would use it if it was available. But it's, it's simply not available in the United States and most places.

Joe Gaccione 4:35
So now we get into this review. Can you talk about what this National Review uncovered?

Jennifer Vanderlaan 4:40
Well, the short answer to that question is that there are actually benefits to the birthing person when water immersion is used and there are some that are specific to the use of water immersion in a hospital. These benefits are an increase in intact perineum and a reduction in postpartum hemorrhage. But the longer answer is that this project was designed so that we could make sense of prior meta analyses. None of the prior work found problems with water immersion, but the prior studies didn't agree about whether or not there were benefits. When I look at the results of the meta-analysis, I find a statistical signature, that tells me as a researcher, that the studies aren't measuring the same thing. Now normally, when this happens, that means that the people who are doing a study are using different measures for their outcomes. But this doesn't make sense for waterbirth because almost all the options, or all the outcomes they're measuring are yes/no options taken from the medical record. So, there shouldn't be this, this statistical signature, just because they're not measuring the same thing. One of the prior meta analyses stood out because it had very little of this variation, we call it heterogeneity, that's just the statist– sorry, statistical signature. So, one study stood out because it had very little of this. And that was a meta-analysis that my team published in 2017. In that particular meta-analysis, we only looked at studies completed in hospitals. We did that because in the United States, 98% of births occur in hospitals. So, what happens in hospitals was a really important part of the question for us. We were surprised when we finished the research, and found very little heterogeneity because it had been so established that the evidence was divided. Our review demonstrated that the evidence for water immersion in hospitals wasn't divided, there appeared to be some potential benefits. So, based on those particular findings, we approached this study really expecting that we could find the reasons for this heterogeneity. Why was the evidence divided? We expected to test different ways of providing care, things like the way that labor inductions are done or different methods for listening to the fetal heartbeat, those kinds of things that maybe those were making a difference in what the outcomes were. One of the things that we decided that we should measure is the setting for childbirth, whether it was in a hospital or somewhere else. So, in the end, this study did demonstrate that some of the heterogeneity reported in the prior studies was due to these differences, like in the type of care provided. One example of that is when we controlled for the rate of episiotomy and the proportion of the sample that were giving birth for the first time, we found there was very little heterogeneity in the analysis for intact peritoneum and the outcome was 100% better when women give birth in water. So, this study, what this study really adds is it helps us identify what are the actual benefits of water immersion. And I wrote down the list for you so that I had it here. The maternal benefits are the reduced use of opioids, the reduced use of epidural, reduced reports of pain, reduced use of episiotomy, increased rate of intact perineum, reduced postpartum hemorrhage, and increased maternal satisfaction. And we also found there's a possible reduction in maternal infection, but we had very few studies to do that so we need to look at that more. And the neonatal benefit was an improved five-minute Apgar.

Joe Gaccione 8:09
It almost seems ironic that you use epidurals, you use certain medications to relieve that pain, to almost numb it, but yet, by reducing the use in waterbirths, it's actually better for the mom.

Jennifer Vanderlaan 8:21
Potentially. We didn't measure whether or not the rate of epidural was having any effect on some of these, some of these outcomes.

Joe Gaccione 8:30
Just they, they used it less.

Jennifer Vanderlaan 8:32
Right, right. We just know that they used it less. And part of that is because we didn't have, we didn't have justification in the prior literature to tell us that, you know, “Well, maybe use of epidural is part of what's leading to episiotomies,” that just doesn't exist in the literature and without a justification for that, we didn't feel that we needed to test for it. But we did have, we did have other things. For example, the intact perineum, the reason that there is an improved intact perineum, part of it is there's a reduced use of episiotomy which when you think about how these studies have been conducted all over the world, all different kinds of hospitals with all different kinds of practices, it makes sense that in some hospitals where they do a lot of episiotomies, you're gonna find a really big drop in the intact perineums because an episiotomy cuts the perineum, and in places where they don't use a lot of episiotomies, you might see almost no difference with water immersion because they're not tearing the perineum, the only tears you're gonna get are the ones that are natural. But what's really interesting is, once we controlled for that, it still showed there was a reduction with waterbirth, which is pretty exciting.

Joe Gaccione 9:39
Were there any drawbacks that you found to waterbirths in this review?

Jennifer Vanderlaan 9:42
There, in this review? Yes, there is one drawback and that is there's an increase in what we call cord avulsion. That's when the, the umbilical cord snaps at birth. It's, it turned out to be very rare in this, in this analysis. We did have a couple of studies that looked at it. The overall analysis told us that there was a higher rate. But, one study was so large that it was 97% of the weight of that analysis was due to one study. And when we removed that one study, there was no longer an increase in cord snap. And interestingly, that study had been done in a, in a midwifery setting, not in a hospital. When we looked at just the hospital settings, there was no increase in cord snap. So, it might be that maybe midwives just have, naturally have a lower number of cord snaps, than in hospitals, well midwives who work in other non-hospital settings have a lower number of cord snaps and so it just shows up in waterbirth, that, that increases their, based on their low rate, not based on hospitals’ rates.

Joe Gaccione 10:46
Okay. I want to get a little more in the weeds for a second. Now you are one of the coauthors of this study, who were the other researchers that you worked with?

Jennifer Vanderlaan 10:52
I worked, one of them was Priscilla Hall. Dr. Priscilla Hall is an assistant professor at Emory University and this is my third meta-analysis that I've conducted with her on waterbirth. The lead author is Dr. Ethel Burns, who is at Oxford Brookes University in the UK, and Claire Feeley, who is also in the UK. Dr. Burns, who is the lead author, published the very first systematic reviews on waterbirth, way back in, I think it was 2004. She has been doing this a long time.

Joe Gaccione 11:29
Wow. When you get together and you propose doing a big review like this and when we talk about 36 studies, at least 150,000 women involved in these studies, how do you know when to stop? How do you know when to say, “36 studies is more than enough, 150,000 women is more than enough?”

Jennifer Vanderlaan 11:45
Oh, that doesn't even come into it.

Joe Gaccione 11:47
It doesn’t?

Jennifer Vanderlaan 11:48
No, it doesn't. The way that a systematic review works is that you have a very defined inclusion and exclusion criteria, and a very defined search strategy. And so, you employ your search strategy, you find all the studies that are potentially able to be included. And then you go through each study individually to see if it meets the inclusion or exclusion criteria. And then when you're done, you search for missing papers, things that you might have missed, you go through the reference list of every study that is in your study to see if there's something that you missed that might be included, and you have to periodically run your search again to see if anything new had been published. So, we didn't pick this number as “enough,” this is just the number that met our inclusion criteria.

Joe Gaccione 12:37
Okay. I want to circle back to something we spoke about at the beginning about access to natural birth sites. Why is there a lack of access for waterbirth?

Jennifer Vanderlaan 12:47
Okay. One of the challenges that people face when they want to use water immersion in labor is that water immersion isn't anything that's tracked in any of our population level data. We have this problem in the United States that things that nurses do are sort of covered in the hospital fees. It's just part of the day fee. If the nurse is working with the laboring woman to get in some different positions or doing some back rubs, none of that gets charged. We have no idea how often nurses are doing that. What does get charged and what we do have evidence on is what the physicians do, the procedures. We know how many Caesarians there are, we know how many epidurals there are, we, you know, anything that the hospital can bill for, we have evidence on. So, we don't really know how common or how effective some of these things are at the population level, it all has to come from these studies because we don't measure it. And this is really common with midwifery and nursing interventions, because they're not included in the billing data. So, if you're not included in the billing data, it's really hard to justify economically why a hospital should invest in having water immersion. And remember, you're trying to convince them to bring in something that's going to reduce the use of an epidural, which is something that they can bill for. So, if you can't make an economic argument, you're not going to get past the CFO.

Joe Gaccione 14:10
Are water immersions typically at home, are they at birthing centers, are there, are those the two primary spots where you can have that or can you have them at hospitals?

Jennifer Vanderlaan 14:18
You can have them at hospitals. There are some hospitals in the United States that have water tubs and, and encourage women to use them. When my daughter was born way back in 1999, the hospital had a tub, they encouraged women to use it during labor, but they didn't do births in it. It wasn't an appropriate tub for birthing. But there are, there are hospitals, they're not in every community but they do exist.

Joe Gaccione 14:41
And we have, this is a shameless plug, but we do have a birthing center here in town, Serenity Birthing Center.

Jennifer Vanderlaan 14:47
Yes, we do.

Joe Gaccione 14:48
Which is, as of this year, the first freestanding birthing center in Southern Nevada, it was actually founded by one of our school’s alumna, April Clyde.

Jennifer Vanderlaan 14:59
Yes, they, and I’ve been there, they have waterbirth tubs in both of their birth rooms.

Joe Gaccione 15:03
And they're huge. I've been there as well, they, they are, if you just like hot tubs in general, it's, it's like a dream. Were you, were you surprised by any of the data from this review?

Jennifer Vanderlaan 15:14
Even though I knew from our review that we, that it was, the evidence was pretty clear and clean on hospitals, I was still surprised with this study. The prior review that we had done only looked at the neonatal outcomes and this study looked more at the maternal outcomes. So, I was, I was really pleasantly surprised that we got such that we were able to measure these benefits, and to actually be able to explain why sometimes they're not seen in the literature.

Joe Gaccione 15:44
Where does the research go from here?

Jennifer Vanderlaan 15:45
The, there's a couple things that we need to do. One of the things that we need to do is we need to figure out, what are the protocols that are going to allow the largest number of women to use water in labor safely and effectively? Right now, because the research is still sort of focused on demonstrating that there's these, you know, that it's safe, that nobody's done the research for quality improvement and implementation to clean up what we use for our protocols. So that's a really big piece that we need. The other piece that we need is we need to figure out how to implement waterbirth on a better scale in the United States. We have a little bit of a different labor and delivery system that they have in most parts of the world where they use water immersion in labor. The difference is we don't staff our hospitals with midwives, we staff our hospitals with nurses. So, when you read, example, protocols from other countries and when you read these studies, a lot of what is happening is the midwife for the physician is sort of in charge of everything. And that makes sense when you think about the midwife is there at the bedside, there's no nurse. So, we need to figure out, what can the nurse do on his or her own without having to have the midwife on-site, because we do have, we do have hospitals where midwives and physicians are on-site all the time but we have a lot of hospitals in the United States where that is not what they're doing. They don't have the capacity to do that in their regions. And in order to bring waterbirth to those types of places, we have to clearly define what is within the scope of the nurse.

Joe Gaccione 17:22
And that leads me to a final question that I was thinking about, when it comes to talking about waterbirths, there are probably families out there who might be considering it but they have to understand too, this is not just something you can do at your house without a health professional, correct? You need to have the right resources, even if you want to pursue this.

Jennifer Vanderlaan 17:41
Yes, when we did a study of, we looked at case studies of poor neonatal outcomes with water immersion and there were two things that we found were really associated with poor outcomes. One was using contaminated water. Now hospitals have to test their water all the time, right? I mean, this is just part of what a hospital does. But families at home don't always think about whether they have a pathogen in their, in their water source, you know? So, but again, that, that wouldn't necessarily matter so much as long as you're not aerosolizing it. So, if your thought is, “Well, I'm just going to give birth in my backyard hot tub,” that's really not a good idea. A hot tub is not a birthing tub. You could have a low level of pathogens that you don't know about that, when, if the Jets are on, you can get aerosolized and the infant can get pneumonia. And so, we saw that going on in home births more often than in hospital births in that case study. So, so there's that piece, you know, the other piece is, you really need to have somebody who understands what waterbirth is and understands the protocols. The other thing that we found really associated with poor outcomes, was not following standard protocols for water immersion, that either somebody thought they knew what they were doing and hadn't actually been trained or just didn't, chose not to follow protocols for what is and is not healthy for being in the water.

Joe Gaccione 19:07
As we wrap up, final question, for resources about waterbirths and where families can go, what do you recommend?

Jennifer Vanderlaan 19:14
I recommend if you don't have water immersion available at your local hospital, and verify that you do, definitely go on the hospital tour before you decide and make sure that what they have is actually a birth tub and not just a labor tub, check with your childbirth educators and your doulas in the community. They can tell you what other resources are available. Not every community has a birth center, but you might be close enough to a birth center with a waterbirth tub that you can use. It's also possible you know, so your, your home bathtub isn't really appropriate for, for most people, their home bathtub isn't appropriate for waterbirth. It's just not deep enough. But you can rent tubs that are appropriate for waterbirth if you want to have a waterbirth at home with a midwife.

Joe Gaccione 19:55
Dr. Vanderlaan, thank you for joining us. It's been a pleasure. For everyone out there, thanks for listening, hope you have a great day.

Transcribed by https://otter.ai