Exploring the Evidence for Water Birth

Water birth is proving to be 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 and 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 water birth has been growing in popularity ever since. McIntosh (2011) suggests that the demand for water birth is now so great that 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 (head-first) presentation
• At least 37 weeks gestation.

(Pregnancy, Birth & Baby 2020)

Benefits, Risks and Contraindications for Water Birth

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

• Water immersion is when the labouring woman remains in a pool of warm water during the first stage of labour but gets out before the baby is born
• Water birth is when 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 (ACM 2013).

Potential Benefits of Water Immersion and Water Birth for the Mother

• Less pain
• Reduced need for pain relief
• Potentially shorter first stage of labour
• Higher satisfaction with the birth experience.

(RANZCOG 2021; Pregnancy, Birth & Baby 2020)

At this stage, water immersion and water birth do not appear to affect:

• Mode of birth
• Risk of serious perineal tear
• Risk of maternal or neonatal infection
• Resuscitation or admission to the neonatal intensive care unit (NICU).

(Cluett et al. 2018; RCM 2018)

Risks of Water Immersion and Water Birth

Despite the common concern that neonates may experience respiratory difficulties or drown upon being born in water, current research suggests that water immersion and water birth pose no increased risk to the mother or baby compared to giving birth on land (RANZCOG 2021).

However, due to the small size of these studies, further research is still required (RANZCOG 2021).

Contraindications for Water Birth

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

Previous Obstetric History:

• Postpartum haemorrhage > one litre
• Caesarean section delivery when the labour and/or birth cannot be monitored electronically
• Shoulder dystocia.

Medical History:

• Insulin-dependent diabetes.
• Active herpes
• Known HIV positive
• Alcohol or drug misuse
• Pre-existing comorbidities that may affect the mother’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 (including the commencement of labour).

During Labour:

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

(SA Health 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.

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 of hospital labour wards.

More studies are also needed related to women’s personal experiences of water birth along with those of midwives and other carers. Poder and Larivière (2014) comment that 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 in regards 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.

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

Additional Resources

• Position Statement on the Use of Water Immersion for Labour and Birth | ACM
• Water Immersion During Labour and Birth | RANZCOG

References

• Australian College of Midwives 2013, Position Statement on the Use of Water Immersion for Labour and Birth, ACM, viewed 18 June 2021, https://www.midwives.org.au/sites/default/files/uploaded-content/field_f_content_file/acm_position_statement_on_the_use_of_water_immersion_for_labour_and_birth_20191022_0.pdf
• Cluett, E R, Burns, E & Cuthbert, A 2018, ‘Immersion in Water During Labour and Birth’, Cochrane Database of Systematic Reviews, viewed 18 June 2021, https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD000111.pub4/full
• 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, Bridgewater Community Healthcare NHS Trust, 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
• 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
• Pregnancy, Birth & Baby 2020, Water Birth, Pregnancy, Birth & Baby, viewed 18 June 2021, https://www.pregnancybirthbaby.org.au/water-birth
• Royal Australian and New Zealand College of Obstetricians and Gynaecologists 2021, Water Immersion During Labour and Birth, RANZCOG, viewed 18 June 2021, https://ranzcog.edu.au/RANZCOG_SITE/media/RANZCOG-MEDIA/Women%27s%20Health/Statement%20and%20guidelines/Clinical-Obstetrics/Water-immersion-during-labour-and-birth-(C-Obs-24)_March-2021.pdf?ext=.pdf
• Royal College of Midwives 2018, Midwifery Care in Labour Guidance for All Women in All Settings, RCM, viewed 18 June 2021, https://www.rcm.org.uk/media/2539/professionals-blue-top-guidance.pdf
• SA Health 2017, Policy for First Stage Labour and Birth in Water In South Australian Public Health Services, Government of South Australia, viewed 18 June 2021, https://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-nDVkhnl