Dreaming in Epistemology a.
Wax, MD and Jeffrey L. This document reflects emerging clinical and scientific advances as of the date issued and is subject to change.
The information should not be construed as dictating an exclusive course of treatment or procedure to be followed. Immersion in water during labor or delivery has been popularized over the past several decades. The prevalence of this practice in the United States is uncertain because it has not been studied in births outside of the home and birth centers, and the data are not recorded on birth certificates.
Among randomized controlled trials included in a Cochrane systematic review that addressed immersion in the first stage of labor, results were inconsistent with regard to maternal benefits. Neither the Cochrane systematic review nor any individual trials included in that review reported any benefit to the newborn from maternal immersion during labor or delivery.
There are insufficient data on which to draw conclusions regarding the relative benefits and risks of immersion in water during the second stage of labor and delivery. Therefore, until such data are available, it is the recommendation of the American College of Obstetricians and Gynecologists that birth occur on land, not in water.
A woman who requests to give birth while submerged in water should be informed that the maternal and perinatal benefits and risks of this choice have not been studied sufficiently to either support or discourage her request. Facilities that plan to offer immersion during labor and delivery need to establish rigorous protocols for candidate selection; maintenance and cleaning of tubs and pools; infection control procedures, including standard precautions and personal protective equipment for health care personnel; monitoring of women and fetuses at appropriate intervals while immersed; and moving women from tubs if urgent maternal or fetal concerns or complications develop.
Recommendations The American College of Obstetricians and Gynecologists the College makes the following recommendations: Therefore, until such data are available, it is the recommendation of the College that birth occur on land, not in water.
She also should be informed of the rare but serious neonatal complications associated with this choice. The opinions expressed in this document should not be interpreted in such a manner as to prevent the conduct of well-designed prospective studies of the maternal and perinatal benefits and risks associated with immersion during labor and delivery.
The prevalence of this practice in the United States is uncertain because it has not been studied in births outside of the home and birth centers, and the data are not recorded on birth certificates 1. In other countries, the prevalence of water immersion varies with birth setting and cultural factors 23.
For example, the United Kingdom recently reported rates of immersion ranging from 1. Several professional organizations, including the Royal College of Obstetricians and Gynaecologists and the American College of Nurse—Midwives, support healthy women with uncomplicated pregnancies laboring and giving birth in water 56.
The purposes of this Committee Opinion are to review the current literature concerning the reported benefits and risks of immersion in water during labor and delivery and, based on these data, to provide updated clinical recommendations and support for well-designed research regarding these practices.
Evidence Regarding Immersion in Water During Labor and Delivery It is important to recognize the limitations of the relevant studies concerning immersion during labor or delivery.
There often is not a uniform definition of the exposure itself. Not all studies identify the point in the course of labor at which immersion was undertaken, considering together the outcomes for all women undergoing immersion in the first stage of labor, second stage of labor, or both 2, 8.
Outcomes indicating safety or risk in association with immersion at one stage of labor may not translate into equivalent outcomes at a different stage of labor; specifically, outcomes during the first stage of labor may not be the same as outcomes associated with birth under water.
In addition to this important limitation, many studies do not fully describe the conditions under which immersion occurred, including duration of immersion, water temperature, depth of the bath or pool, and whether or not agitation jets or whirlpool was used 1, 2, 8 — Additionally, when reported, conditions vary across studies.
Studies of outcomes associated with immersion during labor and delivery include retrospective, prospective observational, and randomized clinical trials. Retrospective studies, which often report data from a single center, cannot demonstrate causal relationships between observed outcomes and exposure to immersion.
Retrospective and prospective observational studies categorize results, including those from labor with second-stage immersion through delivery, according to the actual rather than the intended exposures to immersion 4, 9, 11, 13— In doing so, the analyses may inappropriately exclude or reassign outcomes from the immersion group to the unexposed group.
The results of this approach may overestimate the salutary effects and underestimate the adverse effects observed with immersion.
These misestimations may be accentuated when women undergoing water immersion exhibit fewer obstetric risk factors than those not undergoing immersion 9. Rather than considering all intended underwater births as a single study group, another report analyzed these deliveries as two distinct groups: This approach precludes drawing conclusions regarding the relative merits and risks of intended delivery while submerged.
In considering the evaluation of outcomes, it is important to note that obstetrician—gynecologists and other health care providers involved in providing or studying immersion therapy are not masked to either the treatment or the outcomes and, especially in nonrandomized studies, outcomes may be influenced by differences in the environment attending a particular choice of delivery.
Because of their sample sizes, most individual trials of immersion therapy are limited in their power to detect differences in rare outcomes. Randomized controlled trials RCTs would be ideal to address many of the aforementioned concerns.
A Cochrane review identified 12 relevant and appropriately designed RCTs of immersion during labor, which involved 3, women. Nine of these trials involved immersion during the first stage of labor alone one of nine trials compared early immersion with later immersion during the first stagetwo trials involved first stage of labor and second stage, and one trial involved comparing only the second stage of labor with the controls.
Even among these RCTs, however, some limitations remain, including concerns about power and how the absence of blinding may affect definition of outcomes.
The systematic review also noted that most trials have small sample sizes and, thus, a high risk of bias.Global Immersions' customized Group Homestay Programs are designed for a total English immersion experience.
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