The Effectiveness of Water Birth Versus Normal Birth in Reducing the Intensity of Pain in Mothers - Research Paper Example

SCHOOL OF HEALTHCARE SCIENCES Assessment Front Sheet This sheet must be used as the first page of all work submitted Student ID number: C1560279 Module code:HC3134 Module name: Evidence Based Practice Declared word count: 3,139 Summative work must be submitted via Learning Central by 12.30pm on the due date Students are required to keep a copy of all work submitted ________________________________________________________________ I confirm that the material contained in this assignment is my own work and no part of it has been undertaken by or with others. Where the work of other authors has been drawn upon it has been properly acknowledged and referenced according to appropriate academic conventions. Reference to quotations from other authors has also been correctly acknowledged and referenced within the work. I have read the University’s definition of unfair practice and the related regulations and am aware of the potential penalties which may be incurred for breaches of these regulations. I have read the School’s Maintaining Confidentiality & Anonymity in Academic Work policy and am aware of the potential penalties which may be incurred for breaches of these regulations. By submitting this assignment, you are confirming that it is your own work and does not involve plagiarism, collusion or breaches of confidentiality & anonymity Content page: Title Page number Introduction 2 Aim 3 Search Strategies 3 Assignment Topic 4 Literature Reviews 5 – 8 Local Evidence 9 Recommendation 9-10 Action Plan 10 Conclusion 11 References 12-13 Appendix 14-16 The effectiveness of water birth versus normal delivery/birth in reducing the intensity of pain in mothers during delivery. Introduction: Evidence based practice is described as clinical care critical thinking strategy, which consolidates the meticulous use of existing best practice from patient preferences and values, a clinician’s expertise and well-designed studies (Hoffmann et al., 2010, p. 4). It allows the employment of the best evidence in medical decision-making process by combining current research findings with skilled personnel, while considering the preferences and clients conscience (Eizenberg, 2010, p. 33; Salmond, 2007, p. 114). Evidence Based Practice (EBP) illustrates the ability to reduce differences in patient outcomes, lower healthcare costs, enhance clinical results, and increase safety of the patient (Black et al., 2015, p. 14). In this regard, EBP will play a major role in assisting Oman to attain its mission of accomplishing health vision 2050, which is highly based on health system and patient concern (Ministry of health, 2014). EBP will help Oman to employ nursing and midwifery care approaches that will address patient preferences and value, and thus improving the general patient outcome in Oman. Oman healthcare focuses on providing effective and safe practice to all its patients. In this regard, nurses and midwives are expected to employ their competence and knowledge to ensure that this is attained (Brown et al., 2008, p. 372). Nurses and midwives in the healthcare are required to employ EBP to address the current and future problems the healthcare is or may be experiencing to be able to attain its vision 2050. Assignment Topic Pain management during labour is one of the main challenges being experienced by midwives in Oman (Local hospital, 2014). Most women believe that the use of water during labour can delay labour progress, by reducing the pain (Local Hospital, 2014). In this regard, most traditional midwives advice women not to use the water during labour. In this regard, most women prefer the use of pharmacological pain reduction medication to control labour pain. The use of these drugs has been increasing on yearly basis. The statistics demonstrate that 75 injection Pethidine ampules were given in varying strengths in January 2013 (Local Hospital, 2014). However, this amount had tripled by January 2015; after two years. This demonstrates that the rate of drugs use to relief labour pain is increasing at a high rate (Local Hospital, 2014). Although the Code of Professional Conduct for Nurses and Midwives requires that patient’s autonomy should be maintained, this is proving to be hard in Oman, since there are no choices in mother’s position during delivery. Water birth has been ruled out almost completely in the region (Oman nursing and midwifery Council, 2011). This is either due to lack of enough information regarding the use of water birth or misinformation on the same. In this regard, mothers are only left with one option of land birth. Midwives are also forced to use this technique even when they are sure that the use of water would be best for labouring mothers. The current problem may need to be addressed by obtaining enough information regarding water birth efficiency in labour pain management. The region needs to identify the best labour pain management practice to address this problem. Thus, nurses and midwives in Oman healthcare facilities should consider employing the five major evidence-based practices (EBP) steps, to resolve this problem (Ammouri, et al., 2014, p. 538). These steps are: asking the essential clinical question; gathering best and most relevant evidence; evidence critical appraisal; evidence integration with patient preferences and clinical expertise to arrive to a practice decision; and finally evaluating the decision outcome (Cleary-Holdforth & Leufer, 2008, p. 43.). Aim: To review the literature for this study, the research question is formed and stated using the PICO acronym which stands for (P) population, (I) intervention, (C) comparison and (O) outcome (Holland & Rees 2010). In this assignment the PICO statements reads as follows: In mothers during labour, does water birth compared to normal birth (land birth) reduce pain level at all stages of labour? The main aim of this research is to establish and evaluate the effectiveness of using immersion in water as compared to normal birth (land birth) in reducing labour pain in women during the three stages of labour. Search Strategy: Many different databases were used to search for articles relevant to be used for this assignment. Initial database were accessed Cardiff University e-library portal. Other databases used included CINAHL, Cochrane Library, British Nursing Index, and TRIP. Moreover, different midwifery and research books were utilized from OSNI library. Each database produced a number of journals, with the total numbers of journals obtained from all these databases being 73221 journals. These Journals were filtered by use of date of publication where the most recent publications were taken, mostly ranging from 2004 to 2015. The final selection resulted to a total of 20 journals which were subjectively selected by reviewing the actual journal topic and the abstract, to identify the most relevant journals and books based on the research topics. Journals that demonstrated a high aspect of evidence based practice in waterbirth or immersion bath were given the highest priority. The inclusion and exclusion criteria are provided in table 2. The key words which have been used are: Pain relief in labour, underwater birth, natural childbirth, labour water pool, water birth, normal delivery, immersion, labour and birth, immersion bath, hydrotherapy and labour pain. In this assignment 5 articles are critically reviewed. These articles are: four RCTs’ and one study. The main theme of this paper is to evaluate the effectiveness of water birth in reducing labour pain level at all stages of labour. Literature Review: Literature review refers to a critical analysis of a part of published work via classification, summary, and comparison with past research work, theoretical work or reviews of literature (Rees, 2011). This review focuses on supporting this study with evidence which evaluates the effectiveness of water birth versus normal delivery/birth in reducing the intensity of pain in mothers during delivery. Benfield et al. (2015) conducted a randomize trial to assess the effectiveness of hydrotherapy in labour pain management. The trial involved post-test: pre-test design (table 3), where methods repeatedly was employed to test the impacts of water immersion on pain. The trial involved 11 term women experiencing labour. They were immersed in 37oC xiphoid water for a period of 1 hr. Pain measures were taken in the beginning of the study and repeated 15 and then 45 minutes after the hydrotherapy. Inclusion and exclusion criteria are provided in (table 4). The immersion were measured by use of Wilcoxon signed rank test (table3) where two baseline pain score was considered at below 50mm and above 70mm. Pain measures were taken under dry standard situation. The measures were then repeated 15 and then 45 minutes after the hydrotherapy. The pain mean after the first 15 minutes for women with baseline pain of 50mm was 3.2 and 2.8 after 45 minutes. Similarly, the mean pain score for women with baseline pain of 70mm was 30.3 after the first 15 minutes and at 21.7 after 45 minutes. The P value (table3) after 15 minutes was 0.01, while after 45 minutes it was at 0.04. The research concluded that waterbirth lowered the level of pain among the labouring women. Benfield et al. (2015) studied a small sample which can introduce bias problem where the trustworthiness of the result is impacted and thus, generalization is not upheld (Holland and Rees, 2010). A similar result was obtained in a randomised control trial carried out by Clutter et al. (2004) to evaluate the impact of immersion on labour pain management. The inclusion criteria include women containing cervical dilation of 1cm per hour. Those with higher or less dilation per hour were excluded. The research involved 99 nulliporous women. The trial focused on comparing the maternal pain score for 49 women, who were immersed in water and 50 women, who were assigned to standard pain management. After the first 30 minutes the pain mean score among immersed women was measured by use of visual analogue scale (VAS) to be 49, while the mean score for the control group was measured to be 64. The second measure after another 30 minutes demonstrated -29 mean score for immersed women, while the control group recorded a mean of 12. Although Clutter et al. (2004) used a larger sample size as compared to Benfield et al. (2015); the two researches demonstrated that water immersion has a considerable ability to manage labour pain, as compared land birth. Similarly, Lee et al. (2012) conducted randomize controlled trial to evaluate the efficiency of warm water birth in reduction of labour pain, maintaining the water temperature at 37oC. The water birth lasted for 20 minutes. The inclusion criteria in this research included singleton pregnancy women with anticipation of uncomplicated virginal birth and with dilation of 4cm during the enrolment. The research included a sample size of 130 women. The pain was measured at 4cm dilation and 7cm dilation. It was established that women who took part in warm water bath demonstrated lower pain scores at 7cm and 4 cm cervical dilation as compared to the control group. The pain was lower than that of the control group at 4cm and 7 cm by β = 1.48 and β = 1.65 respectively (Lee et al., 2012). The research concluded that waterbirth plays a significant role in pain management. The three authors Lee et al. (2012), Clutter et al. (2004) and Benfield et al. (2015) used Visual Analogue Scale for Pain (VASP) to measure the level of pain. This is a tool which is simple to apply, and that can be used to measure all forms of physical pain. Therefore, the tool was highly valid and reliable for pain assessment as reported by Lee et al. (2012) and Eberhard et al. (2005). De Silva et al. (2007) conducted randomized control trial to establish the impact of an immersion bath on labour pain management in the first labour stage. The trial involved contrasting pain scores of non-bathing and bathing nulliparous women during birth. The trial included a total of 108 birthing women, where each group was randomly assigned 54 women. The inclusion criteria were full-term nulliparous women containing live, cephalic singleton foetus, active labour, absence of obstetrical or clinical complications, and cervical dilation of 6 cm or less at the admission time. Birthing women were immersed in water bath at 6-7cm cervical dilation for 60 minutes. The pain was measured using numeric scale and behavioural pain scale and they were recorded at two points of evaluation at cervical dilation of 6-7cm and 1 hour after the first evaluation. The behavioural scale had a mean of 2.1 for both groups in the initial evaluation, while numeric scale recorded a mean score of 8.5 and 8.7 for experimental and control groups respectively. The pain score mean at the second evaluation was higher for both scales in control group as compared to the experimental group. The behavioural scale recorded a mean of 1.9 and 2.4 for experimental and control groups respectively, while the numeric scale recorded a mean score of 8.5 and 9.3 for experiential and control groups respectively. The research concluded that water birth is suitable in labour pain management in the first stage of labour. De Silva et al. (2007) and Clutter et al. (2004) tried to maintain a homogenous sample of nulliparous while conducting their study for both waterbirth and normal birth. This increases the strength of their study by reducing study outcome bias that can be initiated by the characteristic variation of the used women sample (Rees, 2011). Similarly, the four evaluated researches maintained the homogeneity of singlet women, where Clutter et al. (2004) went to an extent of ensuring that all the included women had a dilation of 1cm per hour. Similarly, Lee et al. (2012) ensured that the included women had a dilation of 4cm in the onset of the study. This increased sample homogeneity and thus, reducing the result bias for that particular sample (Rees, 2011). Liu et al. (2014) conducted a study to contrast neonatal and maternal outcomes women who go through water immersion in the first stage of labour to those who go through conventional labour. The study involved Healthy primipara women with cephalic and singleton pregnancies who were admitted in Sun Yat-sen memorial hospital obstetrical department from June 2009 to February 2011. The mothers in the hospital were provided an option to select water immersion or conventional birth. The inclusion criteria were regular prenatal evaluations at the hospital outpatient, aged between 20 and 35 years, in 37 to 42 weeks gestation period, foetal weight of 2.5 to 3.5 kgs and no vaginal delivery contradiction. The exclusion criteria included presence of infectious diseases, vaginal delivery contradiction, and pelvis stenosis. A total of 108 mothers were selected for the study. Among them, 38 women selected water immersion, while 70 women selected conventional labour and delivery. Mother were immersed in water at 35-38oC after 3cm cervical dilation where they were allowed to remain in water for 1 hour. A visual analogue scale (VAS) was employed to evaluate pain during labour for all women. The scale contains 0 to 10 scores where 0 means no labour and 10 great pain. The pain score was measured before entering the water tub and after every 30 minutes after entering into the water tub. During 3cm cervical dilation, the two groups had pain mean score of 10, after the first 30minutes the experiential group had a pain mean score of 6 while the conventional group maintained it at 10. After 60 minutes the experiential group recorded a pain score average of 7 while the conventional group maintained it at 10. The study concluded that water bath is highly efficient in labour pain management during the first stage of labour stage. Large sample size is regarded as the main study strength that provides an accurate results as well as statistical significant powered computed results. It can lower the likelihood of bias in a clinical setting (Rees, 2011).The five researches have a considerable variation in the sample size. Benfield et al. (2015) has a sample size of 11, Clutter et al. (2004) has a sample size of 99, Lee et al. (2012) a sample size of 130, while Liu et al. (2014) and De Silva et al. (2007) have a sample size of 108. In this regard, Benfield et al. and Clutter et al. had a higher chance of bias in their results as compared to De Silva et al. and Liu et al. However, Lee et al. had the largest sample and thus, increasing the chances for accuracy in generalized results (Rees, 2011). Literature Review Summary: The use of immersion baths in time of labour his highly common among hospitals and birth centre globally (Benfield et al., 2010, p. 28). Its extensive use according to this study can be attributed to its effectiveness in labour pain management at different labour stages (Liu et al. (2014); Benfield et al., 2010; Clutter et al., 2004; Lee et al., 2012; De Silva et al., 2007). The reviewed studies demonstrate a significant difference between women who used waterbirth to manage pain as compared to the control group. The assignment employed RCT evidence and review study which are among the most reliable methods that can be employed in a clinical set up. The study demonstrated great benefit of employing waterbirth at different stages of labour, and thus it can be said to demonstrate a great advantage in labour pain management, particularly among women with singleton pregnancy and with no other medical conditions. Local Evidence: The Oman region has for a long time been using normal birth to manage all deliveries apart from one private hospital that employ water birth as an alternative based on mother’s choice (Local Hospital, 2014). Due to the high pain involved in this form of delivery, women in Oman prefer using medication for labour pain management. Thus its use has escalated in the recent past. Most organizations in the region are considering employing different form of labour pain control methods. However, there is misinformation in the region regarding water birth efficiency. Traditional midwives, who are sometimes allowed in the maternity based on women’s choice, have made people believe that water birth delays delivery which is not true (Waver 2014). This misinformation have made women in the region to abscond the most cost effective and evidence based form of labour pain management, to a less satisfying technique. Therefore, introducing this technique in the region may be faced by resistance; despite the research prove that water birth reduces labour pain at all stages of labour (Berghella et al., 2008, p. 449). In this regard, the health management in the region should focus on providing the right information to mothers in the region. This will give them a chance to make informed decision regarding the form of birth and labour pain management they wish to employ, rather than being confined to only one option. Recommendation Water birth has been negatively perceived among Oman community. Mothers in the region have managed to pass information regarding the danger of water birth from one generation to another. This has made mothers to consider using drugs to manage labour pain. Although water birth is not common in the region, the negative perception is a clear indication that introduction of water birth may experience great resistance. This research has established that water birth is the most effective labour pain management technique as compared to normal birth. In this regard, the paper recommends that: The misinformation in Oman community that makes it hard for the locals to accept the application of the best practice demonstrated in the literature needs to be collected to enhance informed and right decision making among labouring mothers. The Oman hospital should consider the introduction of the water birth for labour pain management since it has been proven to be a better method of labour management as compared to normal birth (land birth) (Hoffmann et al., 2010). The Oman healthcare may require employing the current provided water birth guidance in their procedure to ensure improved outcome. In this regard, the local healthcare facilities need to establish a policy that defines the most suitable guideline that should be adopted in the region to enhance better outcome (Cleary-Holdforth & Leufer, 2008). The healthcare organizations in the region should collaborate with other non-governmental organizations that focus on enlightening locals regarding various matters, to teach people more about the effectiveness of water birth approach and to discredit the initial wrong information regarding this technique. Action Plan: To bridge the gap between the current practice and the best practice Oman health organizations will need to: Train its midwives on effective application of water birth approach (Black et al., 2015). To purchase the right facilities needed to enhance the application of water birth To train mothers more about water birth approaches using evidence to convince them on its importance, during their prenatal care (Berghella et al. , 2008) Other measures will include monitoring on change of mothers’ attitude toward water birth approach and its preference during labour and delivery with time. Increase in water birth preference among mothers will be an indication of great success in the action plan implementation. This can be done through observation or interviews Conclusion: Labour pain management has been a great problem in Oman. However, the highest percentage of Oman healthcare organizations has not introduced this birth technique in their maternity services. The research focused on establishing the effectiveness of water birth in labour pain management as compared to normal birth (land birth). The research evidently demonstrated high efficiency in water birth approach to labour pain management. In this regard, water birth can be regarded as the best practice for labour pain management at any stage of labour. Thus, Oman should employ the recommended measures to introduce this form of birth as the best alternatives for labour pain management in their health care facilities. Women should also be enlightened on the benefits of water birth over normal birth, to influence them into accepting this form of birth and to embrace it. References: Ammouri, A.A. et al. 2014. Evidence-based practice knowledge, attitudes, practice and perceived barriers among nurses in Oman. Sultan Qaboos University Medical Journal 14(4), pp. 537-545. Benfield, R.D. et al. 2010. The effects of hydrotherapy on anxiety, pain, neuroendocrine responses and contraction dynamics during labor. Journal of Biological Research for Nursing 12(1), pp. 28-36. Berghella, V. Baxter, J.K. and Chauhan, S.P. 2008. Evidence-based labor and delivery management. American Journal of Obstetrics & Gynecology. pp. 445-455. Black, A.T. et al. 2015. Promoting evidence-based practice through a research training program for point-of-care clinicians. The Journal of Nursing Administration 45(1), pp. 14-20. Brown, C.E. et al. 2008. Nursing practice, knowledge, attitudes and perceived barriers to evidence-based practice at an academic medical center. Journal of Advanced Nursing 65(2), pp. 371-381. Cleary-Holdforth, J. and Leufer, T. 2008. Essential elements in developing evidence-based practice. Nursing Standard 23(2) pp. 42-46. Cluett, E.R. and Burns, E. 2012. Immersion in water in labor and birth. Cochrane Database of Systematic Reviews 2, pp. 1-105. Cluett, E.R. et al. 2004. Randomized controlled trial of laboring in water compared with standard of augmentation for management of dystocia in first stage of Labor. British Journal of Midwifery, pp. 1-6. Collins, M.R. and Dahlgren-Roemmich, D.M. 2013. Water immersion for labor and birth. New York: John Wiley and Sons, Inc. Department of Health Information and Statistics. 2014. Annual Health report. Sultanate of Oman: Ministry of Health. De Silva, F.M.B. et al. 2009 A randomized controlled trial evaluating the effect of immersion bath on labour. Journal of Midwifery 25, pp. 286-294. Eberhard, J. Stein, S. Geissbuehler, V. 2005. Experience of pain and analgesia with water and land births. Journal of Psychosomatic Obstetrics and Gynecology 26(2), pp.127–133. Eizenberg, M.M. 2011. Implementation of evidence-based nursing practice: nurses’ personal and professional factor. Journal of Advanced Nursing 67(1), pp. 33-42. Hoffmann, T. et al. 2009. Introduction to evidence-based practice. In: Hoffmann, T. et al Evidence-Based Practice: Across the Health Professions. London: Churchil Livingstone Elsevier, pp.1-15. Holland, K. and Rees, C. 2010. Nursing: Evidence-based practice skills. New York: Oxford University Press. Lee, S. et al . 2012. Efficacy of warm showers on labor pain and birth experiences during the first labor stage. Journal of Obstetrics, Gynecology and Neonatal Nursing 42, pp. 19-28. Liu, Y., Liu, Y., Huang, X., Du, C., Peng, J., Huang, P. and Shang, J. 2014. A comparison of maternal and neonatal outcomes between water immersion during labour and conventional labour and delivery. BMC Pregnancy and Childbirth, 14(160), pp. 1-7. Local Hospital. 2014. Local Hospital Narcotic Statistical Report. Sultanate of Oman: Ministry of Health. Oman nursing and midwifery Council. 2011. Code of Professional Conduct for Nurses and Midwives in Oman. Sultanate of Oman: ONMC. Polit, D. F. and Beck, C. T. 2010. Essentials of nursing research: Appraising evidence for nursing practice. 7th ed. Philadelphia: Lippincott Williams and Wilkins. Rees, C. 2011. Introduction to research for midwives. 3rd ed. UK: Elservier. Salmond, S.W. 2007. Advancing evidence-based practice: A primer. Orthopaedic Nursing 26(2) pp. 114-123. Smith, C.A. 2011. Relaxation techniques for pain management in labor. The Cochrane Database of Systemic Reviews 12, pp. 1-53. Tourmaire, M. and Theau-Yonneau, A. 2007. Complementary and alternative approaches to pain relief during labor 4(4), pp. 409-417. Weaver, M.H. 2014. Water birth in the hospital setting. Nursing for Women’s Health 18(5), pp. 365-369. Appendix: Table 1 Inclusion Criteria Exclusion Criteria Time span 2005-2015 Below 2005 English language Other language Published Non published Relevant to assignment topic Others Table 2: The key wards used for searching: Pain relief in labor underwater birth natural childbirth Labor Water pool Water birth Normal delivery Immersion labor and birth immersion bath hydrotherapy labor pain Table 3: Terms Meaning Systemic review A rigorous and systematic synthesis of research findings on a research question”(Polit & Deck 2010, p.569). Randomized control trails (RCT) “Method of conducting research involving, usually, an experimental group and a control group. It is regarded as ‘scientific’ method as it allows conclusions to be made concerning the existence of ‘ cause and effect’ relationships” (Holland & Rees, 2010. p.291). Meta-analysis “A technique for quantitatively integrating the results of multiple studies addressing the same or similar research question”( Polit & Deck 2010p.559). Validity “The extent to which a tool of data collection has produced what it was intended to produce” (Rees 2011, p.241). Reliability As stated by Holland & Rees (2010.p.291) it is “related to the accuracy or consistency of the tool of data collection and is an important criterion for the collection sound and accurate data”. Confidence interval (CI) The range of values within which a population parameter is estimated to lie, at a specified probability of accuracy (e.g., 95% CI) ((Polit & Deck 2010, p.550). Visual Analogue Scale for Pain (VASP) Rees (2010) stated that VASP is measuring instrument in the form of a straight line. Respondents indicate their location between the two points on the line, e.g. Most pain ever felt/No pain, extreme anxiety/No anxiety. The points on the scale are given numerical values to allow for statistical analysis. Labor Agentry Pain Scale (LAP) Developed by Hodnett and Simmons-Tropea (1987) measures a mother’s feelings of control during childbirth. Its 10-item inventory includes six positive and four negative descriptions of perceived degree of control experienced during childbirth. Scoring follows a 7-point Likert-type scale format, with 7 (all the time), 6 (most of the time), 5 (more than half the time), 4 (about half the time), 3 (nearly half the time), 2 (only occasionally), and 1 (almost never or never). Possible scores ranged from 10 to 70, with a higher number corresponding with a more positive experience. (Lee, et.al 2010) Rigour “The extent to which the researcher has actively sought to carry out the study to a high standard” (Rees 2011, p.238) P value In statistical testing, the probability that the obtained results are due to chance alone; the probability of a Type I error. (Polit & Deck 2010, p.559). Pre-test post-test design Wilcoxon signed rank test A nonparametric statistical test for comparing two paired groups, based on the relative ranking of values between the pairs (Polit & Deck 2010, p.571). Table 4: Inclusion criteria Exclusion criteria The inclusion criteria for this trial was singleton pregnancy women, aged between 17 and 40 years, with no history of current STDs, Psychological disorders, no past surgical delivery, with labour duration of less than one hour and with low obstetrical complication risks. Women who did not meet these standards were excluded. Read More