DOI: 10.1097/JPN.0000000000000260 Continuing Education r r J Perinat Neonat Nurs Volume 31 Number 4, 303–316 Copyright C 2017 Wolters Kluwer Health, Inc. All rights reserved. Systematic Review of Hydrotherapy Research Does a Warm Bath in Labor Promote Normal Physiologic Childbirth? Jenna Shaw-Battista, PhD, RN, NP, CNM, FACNM ABSTRACT Key Words: bath, hydrotherapy, immersion, labor, Health sciences research was systematically reviewed to midwives, normal birth, pain, physiology assess randomized controlled trials of standard care versus immersion hydrotherapy in labor before conventional child- birth. Seven studies of 2615 women were included. Six his article describes a systematic review of re- trials examined hydrotherapy in midwifery care and found search on warm water immersion hydrotherapy an effect of pain relief; of these, 2 examined analgesia and Tduring labor, followed by standard care and con- found reduced use among women who bathed in labor. ventional childbirth. Use of nonpharmacologic comfort One study each found that hydrotherapy reduced maternal and pain relief methods remains limited in the United anxiety and fetal malpresentation, increased maternal satis- States where labor analgesia, anesthesia, and multiple faction with movement and privacy, and resulted in cervical obstetric procedures are routine.1 Higher international dilation progress equivalent to standard labor augmenta- utilization rates suggest a potential for increased US tion practices. Studies examined more than 30 fetal and hydrotherapy utilization and benefits that may include neonatal outcomes, and no benefit or harm of hydrother- support for labor physiology.1–3 Hydrotherapy promotes apy was identified. Two trials had anomalous findings of normal childbirth through reduced use of intrapartum increased newborn resuscitation or nursery admission after interventions due to neuroendocrine, circulatory, mus- hydrotherapy, which were not supported by additional re- culoskeletal and psychological effects of immersion.4 sults in the same or other studies. Review findings demon- Health research literature was searched to assess the strate that intrapartum immersion hydrotherapy is a helpful state of hydrotherapy science and demonstrable effects and benign practice. Hydrotherapy facilitates physiologic of immersion in labor to promote safe and informed childbirth and may increase satisfaction with care. Mater- use. Randomized controlled trials (RCTs) were identi- nity care providers are recommended to include hydrother- fied and synthesized to support evidence-based practice apy among routine labor pain management options and and consent discussions between healthcare providers consider immersion to promote progress of normal or pro- and childbearing women. tracted labor, particularly among women with preferences to avoid obstetric medications and procedures. BACKGROUND Author Affiliation: University of California, Davis, Betty Irene Moore Hydrotherapy is a common comfort measure and treat- School of Nursing. ment intervention in self and healthcare. A warm Disclosure: The author has disclosed that she has no significant relation- bath at the end of a stressful day can be a relaxing ships with, or financial interest in, any commercial companies pertaining activity in daily life, and immersion hydrotherapy is a to this article. prescribed therapy in multiple clinical specialties for its Corresponding Author: Jenna Shaw-Battista, PhD, RN, NP, CNM, soothing and wellness-promoting qualities.5–7 However, FACNM, University of California, Davis, Betty Irene Moore School of Nursing, Education Bldg, 4610 X St, Ste 4202, Sacramento, CA 95817 intrapartum use remains limited compared with phar- ([email protected]). macologic labor pain relief methods, and hydrotherapy 4,8,9 Submitted for publication: December 24, 2016; accepted for publication: utilization rates vary widely by country. Warm water March 18, 2017. immersion hydrotherapy warrants further investigation The Journal of Perinatal & Neonatal Nursing www.jpnnjournal.com 303 Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. given these discrepancies and public health goals for The frequent use of multiple obstetric interventions evidence-based maternity care and normal childbirth and limited use of hydrotherapy are notable in com- promotion among healthy women. parisons between the US and global counterparts. The Physiologic labor and birth are defined as processes United Kingdom’s 2010-2011 normal birth rate was 42% that begin and progress spontaneously at term, with and more than 3-fold higher than for US women at minimal or no use of medications or procedures, and that time.1,19 Approximately 20% of UK women used result in an uncomplicated or normal vaginal birth, post- epidural analgesia/anesthesia for labor pain in 2000 and partum course, and newborn transition to extrauterine 2005 while US use more than tripled in the same time life.10–12 Desirous positive outcomes of normal childbirth period.16,17,20 Nearly all UK birthing facilities have rou- provide rationale for care practices that facilitate phys- tinely provided intrapartum hydrotherapy since it was iologic parturition and necessitate healthcare providers codified as a standard feature of birthing units more who actively assist women to avoid routine medications than 20 years ago.21 By 1993, 89% of maternity units and procedures when appropriate, such as facilitating in England and Wales offered both labor and birth in nonpharmacologic labor pain relief methods in accor- water.2 dance with patient preferences.13 Growing research ev- Low comparative rates of US hydrotherapy utiliza- idence and interprofessional consensus support the po- tion are surprising from this international perspective tential to improve perinatal outcomes among low-risk and may be changing along with provider attitudes and women by adopting a more judicious approach to use consumer demand. Women in Europe and Asia have of routine obstetric interventions,14 including pharma- ranked hydrotherapy availability among factors impor- cologic pain relief methods and labor augmentation, tant in their selection of birth location22 and reported which may be reduced with hydrotherapy.8,15 perceiving that it signals a healthcare provider’s will- The limited use of hydrotherapy among US labor ingness to support maternal autonomy23,24 and phys- pain relief and coping strategies belies its well-rated iologic childbirth25 with personalized care. There are efficacy. Among US women who gave birth in 2011- no comparable data on US women’s perspectives, and 2012, 8% reported using immersion hydrotherapy in la- little is known about their maternity care providers’ bor and 17% experienced labor and birth without use knowledge or experience with hydrotherapy. Most US of analgesia or anesthesia.1 This may represent a mod- midwives provide hydrotherapy and believe that warm est recent increase in hydrotherapy use; prior national water immersion is a safe and effective pain relief surveys found that 6% of US women used a tub or pool method within their basic scope of practice,26–28 al- during labor in 2000-2002 and 2005.16,17 In a study of though postgraduate training is perceived to support US births in 2000-2002, 89% of women who used hy- knowledge and clinical application.29 Nursing organiza- drotherapy in labor reported that it was “very effective” tions have not issued intrapartum hydrotherapy state- compared with 24% of women who rated narcotics as ments or guidelines like other US maternal-child health such.17 Although immersion hydrotherapy was reported organizations26,27,30–32 although labor support with pro- to provide more effective pain control than narcotics, motion of physiologic processes and nonpharmacologic rate of use was decreased 5-fold in comparison (6% of comfort measures are defined among key aspects of in- women used hydrotherapy and 30% used narcotics).17 A trapartum nursing care.33 follow-up survey of US women who gave birth in 2005 There is consensus on perinatal safety and maternal found that fewer used narcotics for pain relief (16%) benefit of immersion hydrotherapy during labor prior to compared with the prior cohort, but use of pharmaco- conventional birth, unlike underwater birth for which logic labor pain relief methods remained stable other- there are international and interprofessional differences wise, with reports that 67% of women used epidural or in assessment of best practices and evidence quality. spinal analgesia, 7% had general anesthesia, 3% used Publications by US midwifery organizations concur with inhaled nitrous oxide, 2% had a pudendal or other lo- the latest American College of Obstetricians and Gyne- cal anesthetic block, and 10% were unable to identify cologists committee opinion that was endorsed by the pain medications used.1 Among survey respondents, American Academy of Pediatrics and asserts, just 13% reported normal childbirth without labor in- Immersion in water during the first stage of labor may duction or augmentation, epidural analgesia/anesthesia, be associated with shorter labor and decreased use of or assisted delivery, while 63% of respondents had spinal and epidural analgesia and may be offered to 2 or more of these obstetric interventions and 31% gave healthy women with uncomplicated pregnancies birth by cesarean delivery.1 These findings are consis- between 37 0/7 weeks and 41 6/7 weeks of tent with US National Vital Statistics data, which indicate gestation.31(pe321) the cesarean