Evidence-Based Clinical Guideline - Thesis Example

Preparation of Evidence Based Clinical Guideline Informed by Critique of Relevant Evidence Background There is an increasing demand for water immersion by women in different countries because of the awareness that the use of warm water has the potential to increase maternal relaxation and eliminate the need for analgesia. Moreover, there is a perception that water immersion improves the quality of care women receive from midwives. Objectives The main objective of this review is to consider the evidence from three different types of studies about water immersion during the labor phase and a consideration of the outcomes recorded in each study. The studies are mainly a randomized control trial, a systematic review and a qualitative study. Search Methods In order to obtain the articles to be used for the review, the Cochrane Library was searched using relevant search questions and key words. Selection Criteria Selection strategies were identified for each type of study considered in the review. Data Collection and Analysis Data from each study was extracted independently and proper documentation followed. Main Results This review considered three types of studies, namely the randomized control trial, a systematic review and a qualitative study. It emerged that, water immersion presented a reduced need for the use of analgesia during labor. Moreover, women felt more confident and in control of the birth process when water immersion was used. However, one of the studies highlighted that there was a higher risk of infection when water immersion was used. Author’s Conclusion The three studies considered in the review presented evidence that water immersion had the potential to reduce the use of analgesia during the first two stages of labor. However, it also highlighted that failure to take precautions regarding the safety of the water may lead to infections in the unborn baby. Evidently, further research concerning this issue is needed. Plain Language Summary Immersion in Water during Labor This review considers three different types of studies in a bid to gain the evidence of the potential benefits of using water immersion during the first two stages of labor. A close analysis of the results from each study reveals that water immersion may serve to reduce the pain experienced during labor and hence eliminate the need for spinal analgesia that is normally given to women in labor. Even when there is a need for analgesia, the studies reveal that it is usually limited when using water immersion. There is a need for advanced research in this sector because the available evidence does not give conclusive findings on the rate of infection during water immersion. Background Information In the 21st century, water birth has become one of the choices that women make regarding their preferred methods of delivery. There has been an increasing controversy regarding the potential benefits of water birth as well as the new challenges it may pose. This necessitates the presence of a clinical guideline that highlights the critical issues related to water birth (da Silva, de Oliveira, & Nobre, 2009). Notably, it has become an option for Australian and New Zealand women and the clinical guidelines must in be in conformation with the Australian health policies. The focus of the guideline will be to explain how the use of warm water during the first two stages of labor should be conducted by the midwives. The guidelines will highlight the potential benefits of relying on the use of warm water during labor (Jessiman, 2009). Notably, there is a difference between labor in water and the expulsion stage conducted in the water. In this guideline, the focus will be on the first two stages of labor in a pool of warm water. However, the guideline will not extend to giving birth in water. The guideline that will be developed below will serve to inform midwives as well women opting for this method of delivery to be more informed on the precaution that they should take when laboring in water. In the case of midwives, the guideline will serve as a reference point since it is informed by evidence based research (Henderson et al, 2014). Throughout the labor in water, the woman must remain attended to by a qualified midwife who closely monitors both maternal and fetal conditions ensuring that both are in a proper state (Yinglin et al, 2014). It is also critical for the midwife to offer relevant advice to the mother to leave the water in case of any determined risk factor emerges which may pose danger to either the mother or the newborn. The recommended temperatures for water birth should not exceed 35 degrees Celsius. Measures of ensuring that the water is not contaminated should be given a priority before the mother can get into the water (Davies, 2012). Monitoring body temperatures of the woman are precautions that midwives should take in a bid to ensure a higher level of safety. In addition, the woman should be encouraged to take a lot of fluids in a bid to counter her staying in warm water (Swain, 2013). The attending midwife should be accompanied by a medical practitioner forming a team of two experts who should be able to offer the recommended level of care if water birth is to be successful (Meyer, Weible, & Woeber, n.d). During the second stage of labor, the woman should be encouraged to indulge in non-directed pushing while the midwife should constantly monitor the head of the newborn using a mirror (Meyer, Weible, & Woeber, 2010). There are precautions required to be taken to ensure that the women does come out of the water for the expulsion phase since this stage is not recommended in the water according to evidence from different studies. There is a need for proper management of the third stage of labor when the woman is already out of the water in a bid to ensure that there is a lower risk of hemorrhage (Benko, 2009). Water immersion presents benefits to the mother the fetus as well as to the care giver. In case of the mother, she experiences numerous physiological benefits brought about by the resulting buoyancy. This means that she delivers in a more relaxed mode compare to other methods of delivery. The fetus also benefits because of the relaxation experienced by the mother as it serves to increase oxygen perfusion. The fact that the mother can move much more easily in water, the fetus has the potential to exhibit a flexed position. Caregivers usually have an easier role to play since women using water immersion are in more control of the birth process and are likely to exhibit high level of confidence. Methods Criteria for Selecting Studies for this Review Types of Studies This review focuses on three different types of studies. They include a randomized control trial, a systematic review, and a qualitative study. In addition, evidence from other studies are included to support the evidence from these three studies considered (Cluett et al, 2004). Types of Participants The review considers the participants from three different types of studies. These participants are women in labor, but only those with a singleton pregnancy. Types of Interventions This review considers one of the strategies used in managing pain during labor. The strategy under analysis is water immersion, but it is worth noting that there are numerous other intervention strategies which have been discussed and examined by different authors (Cluett et al, 2004). Types of Outcome Measures Both primary and secondary outcomes will be considered in the review of the three studies considered. Primary Outcomes Maternal outcomes Fetal outcomes Neonatal outcomes Secondary Outcomes Maternal outcomes Fetal outcomes Neonatal outcomes Search Methods for Identification of Studies Electronic Search In order to identify studies to be used in this review, the Cochran Library was searched using the key words, “Water immersion during labor”. The results that emerged were limited to random control trials in a bid to identify a random control trial to be used in the review. The same was done to identify a qualitative study as well as a systematic review for the study. Since only studies that are less than five years old were needed, a time limiter was also applied. In order to ascertain the relevance of the articles chosen, the abstracts of the articles were considered. Data Collection and Analysis Assessment of Risk Bias in Included Studies Each of the three articles considered for the review was assessed in a bid to establish the level of bias. Each study was considered separately and the risk of bias categorized as either low, high, or unclear. Da Silva, F., de Oliveira, S., &Nobre, M. (2009) In this specific study, women in the controlled group relied on the conventional method of birth while the other group was randomly chosen and relied on water immersion during labor. Both groups received analgesia to relieve the pain resulting from labor. 108 women were selected for the study, which was a reliable sample size. In order to ensure little bias resulting from other factors, women in both groups were exposed to a similar environment with the only difference being the presence of bath tabs that would be used by the group relying on water immersion during labor (Menakaya et al, 2013). The study sought to confirm existing claims that water birth has the potential of reducing the pain experienced during labor and increasing the mother’s comfort in delivery. A close monitoring of the level of pain in both groups was done at different intervals. It emerged that water immersion has the potential of reducing pain during labor. Cordioli (2013) supports this view because of the findings from a study conducted to establish the level of efficiency of water immersion in reducing pain during labor. In addition, Harper (2014) and Jackson (2013) are also in agreement with the fact that water immersion can reduce pain during labor hence eliminate the need for the use of analgesia. Lukasse and colleagues (2014) considered the level of pain relief brought about by water immersion in nulliparous in a bid to establish whether other studies indicating the efficiency of this strategy have been correct. These researchers highlighted that water immersion indeed had a measure of effect in relieving pain during labor. Poder, T. G., & Larivière, M. M. (2014) This study focused on offering a systematic review of the existing literature in databases such as PubMed, Cochrane and Embase. This study was conducted in a bid to clear the existing controversy concerning water birth as method of delivery. Previously, there had been an increased debate concerning the potential benefits of water birth, which may lead it to become a generalized option in different hospitals. According to Jessiman (2009) water birth has the potential to reduce the use of analgesia to relieve pain because the immersion in warm water facilitates a high level of relaxation. Moreover, the fact that water birth places a new requirement for each mother to have a midwife attending to her introduces a new level of maternal health care, which poses a benefit to both the mother and the newborn baby. On the other end, the context of this study also included a consideration of the potential disadvantages of the water birth option to both the mother and the newborn baby according to a research conducted by Kvach & Martonffy (2012). Eckert, Turnbull and MacLennan (2010) cite some of the disadvantages which include the existing risk that the newborn may swallow the water and the high rate of infection, which is possible in the bath-tub or the water pools. The purpose of this study was to carry out a critical review of the existing literature concerning water birth in order to provide evidence that can lead its generalization in different hospitals. In the modern day, water birth is not an option available in all hospitals, but is only limited in some hospitals that have the relevant facilities and expertise. In order to critically review the literature, a systematic approach was adopted which considered all the available literature in the databases mentioned above since 1989 to 2013. With such a long period covered, extensive literature was considered for this systematic review. Moreover, the databases chosen are both reputable and reliable. These factors contribute to the validity of the findings of the systematic review. From the results of the systematic review, it emerged that, water birth is a better option than conventional birth, but only in the first and second stages of labor where is presents certain benefits. However, in the third stage, which is the expulsion stage, water birth is not recommended. In order to ensure that water birth presents the expected benefits during the labor phase, it is critical to take the necessary precautions that minimize the level of infection and that increase the safety of the mother and the newborn (‘Labor in water may be safe, but not water delivery, according to ACOG’, 2014). McKenna, J. A., & Symon, A. G. (2014) This is a qualitative study which focused on understanding the experience of women who have undergone Vaginal Birth after Cesarean (VBAC), but who opted for the immersion in water during the vaginal birth. These women highlighted that several factors contributed to the cesarean in the previous birth and had the conviction that being in a bathtub would prevent the recurrence of such factors. Notably, experts have often insisted on the advantages of vaginal birth after previous cesarean sections in a bid to reduce the increasing rate of caesarean operations (Young & Kruske, 2013). The use of water immersion during VBAC has been emphasized, although there is still a lack of relevant information and evidence that proves the benefits of water immersion. This study sought to highlight the opinion of eight women who had successfully undergone water VBAC. Jackson (2013) and Swain (2013) support the views in this article that water immersion is safe for women undergoing VBAC. Menakava and colleagues (2013) produced evidence that water immersion was safe for women undergoing VBAC. Recommendations During the first stage of labor, women may be allowed to choose the option of water immersion in a bid to experience the potential benefits associated with the use of warm water. However, midwives must ensure that women choosing this option are healthy and do not present any medical risk factors (Papile et al, 2014). Moreover, it must be established that, they are not carriers or infected with the HIV virus as well as hepatitis B or C Viruses. It must be determined that their pregnancy is a singleton. An additional consideration is the body mass index, which is a critical factor in determining the eligibility of a woman using a water immersion during labor (Harper, 2014). Throughout the labor in water, the woman must remain attended to by a qualified midwife who closely monitors both maternal and fetal conditions ensuring that both are in a proper state (Yinglin et al, 2014). It is also critical for the midwife to offer relevant advice to the mother to leave the water in case of any determined risk factor emerges which may pose danger to either the mother or the newborn. The recommended temperatures for water birth should not exceed 35 degrees Celsius. Measures of ensuring that the water is not contaminated should be given a priority before the mother can get into the water (Davies, 2012). Monitoring body temperatures of the woman are precautions that midwives should take in a bid to ensure a higher level of safety. In addition, the woman should be encouraged to take a lot of fluids in a bid to counter her staying in warm water (Swain, 2013). References Benko, A. (2009). Waterbirth: Is it a real choice?.Midwifery Matters, (122), 9-12. Cluett, E., Nikodem, V., McCandlish, R., & Burns, E. (2004). Selected Cochrane systematic reviews. Immersion in water in pregnancy, labour, and birth. Birth: Issues In Perinatal Care, 31(4), 317. Cordioli, E. (2013). Immersion in water in labour and birth.São Paulo Medical Journal = RevistaPaulista De Medicina, 131(5), 364. doi:10.1590/1516-3180.20131315T2 da Silva, F., de Oliveira, S., &Nobre, M. (2009). A randomised controlled trial evaluating the effect of immersion bath on labour pain.Midwifery, 25286-294. doi:10.1016/j.midw.2007.04.006 Davies, M. (2012). Water births and the research required to assess the benefits versus the harms. 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Yinglin, L., Yukun, L., Xiuzhi, H., Chuying, D., Jing, P., Peixian, H., &Jianping, Z. (2014).A comparison of maternal and neonatal outcomes between water immersion during labor and conventional labor and delivery.BMC Pregnancy & Childbirth, 14(1), 1-13. doi:10.1186/1471-2393-14-160 Young, K., & Kruske, S. (2013). Review article: How valid are the common concerns raised against water birth? A focused review of the literature. Women And Birth, 26105-109. doi:10.1016/j.wombi.2012.10.006. Read More