Downloaded from http://journals.lww.com/jpnnjournal by BhDMf5ePHKbH4TTImqenVA+lpWIIBvonhQl60Etgtdnn9T1vLQWJq3kbRMjK/ocE on 11/05/2020 J Perinat Neonat Nurs  Volume 34 Number 4, 311–323  Copyright C  2020 Wolters Kluwer Health, Inc. All rights reserved. DOI: 10.1097/JPN.0000000000000515 Systematic Review of Case Reports of Poor Neonatal Outcomes With Water Immersion During Labor and Birth Jennifer Vanderlaan, PhD, MPH, CNM; Priscilla Hall, PhD, CNM ABSTRACT Water immersion is a valuable comfort measure in labor, that can be used during the first or second stage of labor. Case reports of adverse outcomes create suspicion about water birth safety, which restricts the availability of wa- ter birth in the United States. The objective of this study was to synthesize the information from case reports of ad- verse water birth events to identify practices associated with these outcomes, and to identify patterns of negative outcomes. The research team conducted a systematic search for cases reports of poor neonatal outcomes with water immersion. Eligible manuscripts reported any ad- verse neonatal outcome with immersion during labor or birth; or excluded if no adverse outcome was reported or the birth reported was unattended. A qualitative narrative synthesis was conducted to identify patterns in the reports. There were 47 cases of adverse outcomes from 35 articles included in the analysis. There was a pattern of cases of Pseudomonas and Legionella, but other infections were uncommon. There were cases of unexplained neonatal hyponatremia following water birth that need further inves- tigation to determine the mechanism that contributes to Author Affiliations: University of Nevada, Las Vegas, (Dr Vanderlaan); and Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia (Dr Hall). Supplemental digital contents are available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.jpnnjournal.com). Disclosure: The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article. Each author has indicated that he or she has met the journal’s require- ments for Authorship. Corresponding Author: Priscilla Hall, PhD, CNM, Nell Hodgson Woodruff School of Nursing, Emory University, 1520 Clifton Rd NE, Atlanta, GA 30322 (pjhall@emory.edu). Submitted for publication: June 4, 2020; accepted for publication: July 21, 2020. this complication. The synthesis was limited by reporting information of interest to pediatricians with little informa- tion about water birth immersion practices. These data did not support concerns of water aspiration or cord rup- ture, but did identify other potential risks. Water immersion guidelines need to address infection risk, optimal manage- ment of compromised water-born infants, and the potential association between immersion practice and hyponatremia. Key Words: adverse neonatal outcome, obstetrical, water birth W ater immersion during childbirth is an es- sential care strategy that can be used in the first or second stage of labor to promote comfort and relaxation for pregnant people. Women who use water immersion report a greater ease of mo- bility, a stronger perception of safety, having a sense of empowerment, and a more positive birth experience. 1–3 Water immersion in labor and birth is associated with decreased perception of pain and decreased use of pharmacologic pain management including epidural anesthesia. 4 Use of water birth in the United States remains restricted because of concerns about safety. While the safety and effectiveness of water immersion during the first stage of labor is generally accepted, questions persist about safety during the second stage. 4 Professional organizations are polarized in their sup- port of water birth. The American College of Nurse Mid- wives (ACNM) and the American Association of Birth Centers 5 are in favor of water birth for the benefits of comfort and effective pain relief without any in- creased risk for healthy women. However, the Amer- ican Congress of Obstetrics and Gynecologists and the American Academy of Pediatrics cite inconsistent re- search with maternal benefits, no recognized benefits to infants, and case reports of poor neonatal outcomes. 6 Copyright © 2020 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. The Journal of Perinatal & Neonatal Nursing www.jpnnjournal.com 311