By Taylor Morrison CNM~

Women have sought out hydrotherapy (water immersion) for labor and/or birth since the 1800s.  It has become increasingly popular in the last few decades and is commonly cited as a major reason for women choosing out-of-hospital birth.  While the safety of laboring in water is generally accepted, there are differing opinions among professional organizations in the U.S. regarding the safety of giving birth underwater.  This post will review the potential benefits and risks to mom and baby, current evidence on outcomes for mother and baby, and precautions for safely using water immersion.  Decisions regarding hydrotherapy in labor and/or birth should always be discussed with your health care provider.

Why do Women Choose Water Labor/Birth?

Supporting Natural Birth

Studies show that women who labor in the water are more likely to have a spontaneous vaginal birth (vaginal birth without the use of vacuum or forceps) than those who do not labor in the water (this increase is true whether women gave birth in the tub or not).  The research demonstrates that birthing underwater results in far fewer episiotomies, especially in settings with high episiotomy rates, and fewer severe perineal tears (3rd and 4th degree lacerations), especially in settings with high rates. Many studies have suggested that hydrotherapy may shorten the length of labor and duration of pushing, while other studies have found no difference.  The research has also found a decrease in the use of artificial Pitocin to hasten labor.  Women who use hydrotherapy are also much less likely to use medication (narcotics and epidurals) than those who do not use water immersion during labor/birth.

Pain Relief and Birth Satisfaction

We have already discussed the decreased use of pain medication in women who use hydrotherapy in labor. But how effective is water immersion for pain relief? The research suggests, “Very!” Several studies have compared pain scores and found hydrotherapy to significantly decrease pain scores compared to woman who do not use the tub.  One study even found, when comparing women who used hydrotherapy and women who used narcotic pain medication, hydrotherapy provided greater pain relief than narcotic drugs.  Furthermore, women who used the tub had higher rates of satisfaction with the childbirth experience than those who did not, with 72-81% stating that they would want to use hydrotherapy again in future births.

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Why are some opposed to hydrotherapy?

Many professional organizations endorse the use of hydrotherapy in labor and birth.  These include the American College of Nurse-Midwives, the America Association of Birth Centers, the Royal College of Midwives, the Royal College of Obstetricians and Gynaecologists, the Midwives Alliance of North America, and the National Association of Certified Professional Midwives, among others.  However, in 2014, the American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics (AAP) published a joint Opinion Statement that water immersion during labor/birth has few benefits and increased risks for mother and baby.  They further state that water birth should treated as highly experimental.  However, in 2016, these same organizations (ACOG and AAP) released an amended statement based on a more in-depth, higher-quality review of the available evidence and literature.  In it, they significantly softened their criticism of hydrotherapy and suggested that “water birth may be offered to healthy women with uncomplicated pregnancies…” You can read a summary of the changes between the 2014 and 2016 committee opinions here.  It is helpful to note that much of the criticism you may hear (from doctors, in the media, from friends, on websites) is likely based on this first 2014 Opinion Statement.

What are the concerns/risks associated with hydrotherapy?

Infection

The most common concern regarding water immersion in labor and birth is infection.  Many worry about potential bacteria from feces, the vaginal canal, and hydrotherapy equipment negatively affecting the mother and baby.  Others suggest that water immersion may actually dilute problematic bacteria and decrease its effects.

Research studies show no difference in the rates of maternal infection between women using or not using water in labor/birth.  Studies show no difference in rates of newborn pneumonia infection and bacteria present in the newborn microbiome.  Some research actually demonstrates a decreased risk for non-pneumonia infections and GBS colonization of the nose and throat in newborns born in water compared to those born on land.  Some case reports have reported rare cases of Pseudomonas or Legionella infection of the newborn after water birth; these case reports are anecdotal and are not based on research studies.  It is also important to note that Pseudomonas and Legionella are commonly thought to be from contaminated tubs, tubing, or water birth supplies.

Aspiration

Another common concern is aspiration, or baby inhaling water upon delivery.  It is helpful to remember that babies are aquatic creatures who are immersed in amniotic fluid throughout the pregnancy.  During pregnancy, babies receive oxygen and nutrients via the umbilical cord and have no need for respiration (breathing).  There are several factors that stimulate a newborn to begin breathing for the first time, namely the increased pressure and gravity of air (versus fluid), the decreased temperature of the air, the increased oxygen saturation of the air, and clamping of the umbilical cord (stopping the flow of oxygen from the placenta).  All of these factors require baby being exposed to air or interfering with the umbilical cord.

The only reports of neonatal aspiration are from case studies, which are anecdotal and not based on research studies.  It is thought that these rare instances were caused by the “gasping reflex” of babies experiencing fetal hypoxia or fetal distress in the womb.  Research studies show no difference in the rates of neonatal death, decreased Apgar scores, or the need for neonatal resuscitation.  Other research studies show that babies born underwater actually have a decreased risk for breathing difficulties, neonatal hypothermia, NICU admissions, and post-birth transfer to hospital from birthing centers or homes.

Tearing of the Umbilical Cord

There is some concern for umbilical cord avulsion (tearing or rupture of the umbilical cord) when baby is brought quickly or forcefully out of the water.  Studies do show an increase in rates of umbilical cord avulsion for water births compared to land births.  If not addressed quickly by the health care provider, umbilical cord avulsion may lead to neonatal blood loss, neonatal blood transfusion, and/or NICU admission. However, most of the instances of cord avulsion were not associated with additional neonatal complications, and no neonatal deaths from cord avulsion during water birth have been reported to date.

Perineal Lacerations

Though studies show that severe perineal tears are decreased with water births, there is evidence that minor perineal tears (1st and 2nd degree lacerations) and minor labial tears may be increased in water births compared to land births.  Women giving birth on land were more likely to have an intact perineum (no tears or lacerations) than those giving birth in water.

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How do we mitigate the risks associated with water birth?

Infection

  • Thoroughly disinfect the birthing tub, drains, and all water birth supplies between clients.
  • Fill tub with ordinary bath water without additives.
  • Don’t allow water to sit. Fill up the tub only when needed. Drain, clean, and refill as needed during labor. Avoid closed systems that recirculate and reheat water.
  • Quickly remove fecal matter and other debris with nets. Drain, clean, and refill as needed.
  • Carefully monitor mom and baby for signs of infection with frequent assessments of fetal heart rate, maternal heart rate, and maternal temperature.

Aspiration

  • Never allow baby’s head to be re-submerged in water once it is exposed to air. Once the head is delivered, keep mom and baby underwater until the baby’s body is fully outside the mother. If any part of the head is exposed to air, assist the mother in continuing to birth out of the water.
  • Monitor closely for fetal distress. Remove mother from tub immediately for any issues with the fetal heart rate.
  • Only allow low risk women to use hydrotherapy. Low risk women have uncomplicated pregnancies with one fetus, head-down, between 37 0/7 and 41 6/7 weeks gestation, with normal fetal heart rates.
  • Keep emergency equipment (suctioning, oxygen, resuscitation equipment) on hand at all times.

Umbilical Cord Avulsion

  • After birth, assist in bringing the neonate directly and gently to the surface (within 5–10 seconds) to minimize tension on the umbilical cord and to reduce the possibility of avulsion.
  • Immediately assess the source of any bleeding. Cord clamps should be readily available to stop bleeding in the event of tearing.

Other Considerations

  • Maintain water temperature 100°F or below during labor.  Maintain a strict temperature range of 97-100ºF for water births.  This ensures that the mother will not overheat during labor and that baby will not be exposed to cold water during delivery, which may stimulate the gasping reflex.
  • Ensure that the laboring woman has sufficient mobility and faculties to quickly exit the tub should any complications arise.  Women with impaired mobility should not use hydrotherapy.
  • Maintain hydration through oral or IV fluids.
  • Vaginal exams may be performed in the water.
  • Nitrous oxide may be used during hydrotherapy.
  • After birth, keep baby warm via continuous skin-to-skin with mother and keeping baby’s body underwater.

Who should not use hydrotherapy?

Women who have:

  • Abnormal vaginal bleeding
  • Temperature 100.4 degrees F or greater
  • Musculoskeletal issues or reduced mobility
  • Any condition that requires continuous fetal monitoring
  • Pregnancy conditions that may complicate the newborn’s transition to extrauterine life
  • Active herpes lesion, hepatitis B, hepatitis C, or HIV
  • Epidural analgesia
  • Received narcotic or other sedating medication within 1 hour of hydrotherapy

water birth

Hydrotherapy is an pain management strategy for low risk women during labor and birth. It has been shown to greatly reduce pain and the need for pain medication and improves many maternal outcomes.  Like any birthing option, there are potential risks involved.  With proper surveillance and hygiene, many of these risks can be mitigated.  It is important that any woman desiring hydrotherapy have informed consent about all of the possible risks, benefits, and alternatives.  As with many birthing options, there needs to be more research and investigation to clearly establish all of the possible outcomes.  As always, women considering hydrotherapy should have a thorough discussion with their health care providers.

References

Evidence-Based Birth‘s review of the research:
https://evidencebasedbirth.com/waterbirth/

Review of research in the Journal of Perinatal Education:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4210671/

“A Model Practice Template for Hydrotherapy in Labor and Birth”: A Joint Statement from ACNM, AABC, MANA, and NACPM:
https://onlinelibrary.wiley.com/doi/epdf/10.1111/jmwh.12587

Evidence-Based Birth‘s comparison of the 2014 and 2016 Committee Opinions from ACOG and AAP:
https://evidencebasedbirth.com/comparing-the-2014-and-2016-acog-and-aap-statements-about-waterbirth/

ACOG’s Committee Opinion- 2016:
https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Immersion-in-Water-During-Labor-and-Delivery?IsMobileSet=false