Exploring the Evidence for Water Birth

Water birth is proving an increasingly popular choice for many labouring women, yet controversy remains about its benefits and, above all, its safety.

Why are Water Births Becoming So Popular?

Water births, or water immersion in labour, first became popular back in the 1970s, when it was noticed that women relaxing in water gave birth more easily.

Initial fears about the baby drowning were unfounded and it’s been growing in popularity ever since. McIntosh (2011) suggests that the demand for water birth is now so great, it should be regarded as a core midwifery competence.

Despite a huge rise in consumer demand for water birth in recent years, it’s not suitable for everyone and the following pre-requisites are generally accepted as standard.

• An uncomplicated singleton pregnancy.
• A cephalic presentation.
• A gestation between 37 and 42 weeks.

(South Australian Public Health Services 2017)

Benefits, Risks and Contraindications

When evaluating the research, it’s important to make a clear distinction between water immersion and water birth.

1. Water immersion – the labouring woman remains in a pool of warm water during the first stage of labour but gets out before the baby is born.
2. Water birth – the mother remains in the water until the birth is complete and the baby is safely brought to the surface.

Warm water immersion is now generally accepted as a safe and effective way of relieving the intensity of pain associated with labour, elevating the release of endorphins, increasing the mother’s feelings of control and facilitating relaxation (Australian College of Midwives 2013).

Research into the benefits of remaining in water to give birth is also encouraging and includes a higher rate of normal vaginal birth, a higher rate of intact perineum, less use of episiotomy, and greater satisfaction with the birth overall.

Potential Benefits to the Mother of Both Water Immersion and Water Birth

• Less pain and higher satisfaction with the birth experience
• Less medication used for pain relief
• Less use of artificial oxytocin and possibly shorter labours
• Higher rates of normal vaginal birth
• Lower rates of episiotomy
• Possibly lower rates of  postpartum haemorrhage

(Dekker 2018)

Risks of Water Immersion and Water Birth

It’s widely accepted that the greatest risk of water birth is for the baby, with particular concerns about the increased risk of infection.

Whilst most current research seems to dispel these concerns there continues to be calls for continued vigilance, audit and further research (Royal College of Midwives 2012).

Concerns about the potential risks for both mother and baby include:

• A potential higher rate of mild labial tears from water birth in low-episiotomy environments such as homes and birth centres.
• Umbilical cord snap is a rare but possible occurrence. Care providers need to take care not to place too much traction on the cord when guiding the baby out of the water and identify the source of any bleeding immediately.
• There have been several reports of water aspiration.
• Increased risk of infection in the baby

(Dekker 2018)

Water birth isn’t suitable for all mothers, however, and there are many contraindications that must be excluded before immersion and birthing in water can be considered a safe option.

Contraindications to Water Birth

Previous Obstetric History:

• Postpartum haemorrhage in excess of one litre.
• Caesarean section delivery when the women’s labour and or birth cannot be monitored electronically.
• Shoulder dystocia.

Medical History:

• Insulin-dependent diabetes.
• Active herpes.
• Known HIV positive.
• Alcohol or drug misuse.
• Any pre-existing medical condition that may affect the woman’s labour risk.
• Mobility/skeletal problems that may prevent leaving the birthing pool when necessary.

Current Pregnancy:

• Pre-eclampsia.
• Intrauterine growth restriction.
• Current risk factors for shoulder dystocia.
• BMI > 35kg/m² at any time during pregnancy.

During Labour:

• Meconium stained liquor.
• Febrile or evidence of infection.
• Foetal heart rate abnormalities.
• Intrapartum haemorrhage.
• Maternal opioid use within the previous 4 hours.
• Epidural analgesia.

(South Australian Public Health Services 2017)

Assessing the Evidence

To date, there is relatively limited research on the safety of water births, and most of the evidence that does exist is restricted to healthy women with uncomplicated pregnancies.

Many studies show that some of the benefits of water birth can also be gained with water immersion alone, followed by birthing outside the pool.

Most researchers agree that water birth appears to be associated with a significantly shorter first stage of labour, lower episiotomy rate and reduced analgesic requirements when compared with other delivery positions. As Thoeni et al. (2009) say, if women are selected appropriately and hygiene rules are followed, water birth appears to be safe for both the mother and neonate.

The Royal College of Midwives (2012) provides an excellent review of the current research evidence on potential risks and advantages of water birth. They point out, however, that the use of water during labour and birth continues to be an area with limited high-quality evidence and many researchers have called for further studies.

Important areas for further research include management into the third stage of labour and further analysis of the psychological benefits and effects on maternal satisfaction. Overall, the use of water is believed to encourage a woman-centred approach to care, support the normalising of birth and should be an important consideration in terms of maternal choice.

Cluett et al. (2018) echo the need for further research suggesting that the data available so far is of variable quality. In particular, they call for further research to be carried out in settings outside hospital labour wards.

More studies are also needed about women’s personal experience of water birth along with those of midwives and other carers. Poder and Larivière (2014) comment on the level of evidence of many studies goes from moderate to low. They suggest that whilst it’s possible to recommend immersion in water during the labour phase, no recommendation can be made as regard to the birth itself.

Whilst the benefits of water birth remain under debate among professionals, those in favour suggest it may increase maternal relaxation, reduce analgesia requirements and promote a model of obstetric care more focused on the needs of mothers.

Miller and Magill‐Cuerden (2006) suggest that if we truly wish to make birth healthier and more satisfying for mothers, to enhance job satisfaction for midwives and restore normality in birth, then every woman without major complications should be offered the opportunity to labour and give birth in water. In some contrast to these views, however, major critics continue to cite a risk of inhalation of water for the newborn and a risk of infection for both mother and baby.

As consumer demand for water birth continues to rise, most mothers and midwives would probably agree with Dekker (2018), who says that if a pregnant woman has a strong desire for water birth, and there are experienced staff who are comfortable in attending then there is no evidence to deny women this option of pain relief.

References

• Australian College of Midwives 2013, Position Statement on the use of water immersion for labour and birth, viewed 18 June 2018, https://18-midwives.cdn.aspedia.net/sites/default/files/uploaded-content/field_f_content_file/…2013.pdf
• Cluett, ER, Burns, E & Cuthbert, A 2018, ‘Immersion in water during labour and birth’, Cochrane Database of Systematic Reviews, viewed 18 June 2018, http://cochranelibrary-wiley.com/doi/10.1002/14651858.CD000111.pub4/abstract
• Dekker, R 2018, ‘The Evidence on: Waterbirth’, Evidence Based Birth, viewed 18 June 2018, https://evidencebasedbirth.com/waterbirth/
• McIntosh, J 2011, Guideline for the Management of Water Birth in the Community, viewed 18 June 2018, http://activebirthpools.com/wp-content/uploads/2016/11/Bridgewater-Community-Healthcare-Guideline-for-the-Management-of-Water-Birth-in-the-Community.pdf
• Miller, JB, Magill‐Cuerden, J 2006, ‘All women in labour should have the choice of waterbirth’, British Journal of Midwifery, vol. 14, no. 8, pp. 484-5, viewed 18 June 2018, https://www.researchgate.net/publication/272460772_All_women_in_labour_should_have_the_choice_of_waterbirth
• Poder, TG, Larivière, M 2014, ‘Advantages and disadvantages of water birth. A systematic review of the literature’, Gynécologie Obstétrique & Fertilité, vol. 42, no. 10, pp. 706-13, viewed 18 June 2018, https://www.researchgate.net/publication/263746201_Advantages_and_disadvantages_of_water_birth_A_systematic_review_of_the_literature
• South Australian Public Health Services 2017, Policy for First Stage Labour and Birth in Water, viewed 18 June 2018, http://www.sahealth.sa.gov.au/wps/wcm/connect/ae527200465ec14d8572ff2e504170d4/First+Stage+Labour+and+Birth+in+Water_CD_v4_0.pdf?MOD=AJPERES&CACHEID=ROOTWORKSPACE-ae527200465ec14d8572ff2e504170d4-lZcoKHI
• Thoeni, A, Zech, N, Moroder, L & Ploner, F 2009, ‘Review of 1600 water birts. Does water birth increase the risk of neonatal infection?’, Journal of Fetal Neonatal Medicine, vol. 17, no. 5, pp. 357-61, viewed 18 June 2018, https://www.ncbi.nlm.nih.gov/pubmed/16147851
• The Royal College of Midwives 2012, Immersion in Water for Labour and Birth, viewed 18 June 2018, https://www.rcm.org.uk/sites/default/files/Immersion%20in%20Water%20%20for%20Labour%20and%20Birth_0.pdf