If laboring in warm water or water birth sounds appealing, I have good news. A large review combining data from multiple studies found labor and birth in a deep tub or birthing pool to be safe and beneficial.
Let’s look at the details.
Summary of the Review
What did the reviewers want to know?
The reviewers wanted to investigate the effect of water immersion in labor and water birth on the use of medical interventions and outcomes. “Water immersion” meant laboring in a tub or pool deep enough to cover the belly when seated and large enough to allow freedom of movement.
Who participated?
The review comprised 36 studies and 157,546 participants, almost all of whom were first-time mothers. Most of the data came from studies of immersion for both labor and birth (151,742), and two-thirds of the participants gave birth in hospitals while the rest had their babies in birth centers or their homes.
Did the reviewers find any harms?
The review reported no differences in:
- Shoulder dystocia (the head is born but the shoulders hang up behind the pubic bone)
- Anal sphincter injury
- Heavy postpartum bleeding (generally measured as blood loss of 500 mL—or 1 pint—or more)
- Manual removal of the placenta
- Newborn resuscitation
- Transient tachypnea of the newborn (rapid breathing caused by fluid in the lungs)
- Newborn respiratory distress
- Newborn infection, although this outcome came from one study with only 230 participants
- Newborn mortality
- Breastfeeding initiation
The review reported a small increase in the umbilical cord breaking during the delivery (4 versus 1 per 1000) at water births, probably caused by too much pull on the cord as the baby is brought up out of the water. The excess, though, came from one study, which suggests that it relates to how the birth is managed and is therefore modifiable.
How did immersion affect the use of medical interventions?
Reducing use of medical intervention is itself a benefit because all medical interventions have the potential for adverse effects. Water immersion decreased:
- Labor augmentation (giving IV oxytocin to strengthen contractions)
- Opioid use
- Epidural use
- Episiotomy (snipping the vaginal opening to enlarge it for birth)
Immersion had no effect on cesareans. However, the reviewers point out that cesarean rates averaged 4% in the studies, and all but two studies reported rates of 10% or less. That means results may not apply to settings in which cesarean rates in low-risk women are higher, which they are in most hospitals in the U.S.
What were the benefits?
Water immersion reduced:
- Pain
- Maternal infection
- Low 5-minute Apgar scores (a measure of newborn condition at birth)
And increased:
- Intact perineum (no or minimal injury to the block of tissue between the vaginal opening and the anus)
- Maternal satisfaction
What did the reviewers conclude?
“This review endorses previous reviews showing clear benefits resulting from intrapartum water immersion for healthy women and their newborns.” – Burns (2022)
My Comments
Two thoughts occur: first, this isn’t the only large study to report reassuring results. A recent study matched 17,530 women having water births one-to-one with women having non-water births on over 80 characteristics. It too confirmed the safety of water birth and reported some advantages. As the study’s lead author stated, “This isn’t for everybody, but for some people, this could be a totally viable option.”
Second, care provider practice style could be the real reason for the study’s results. Care providers who are comfortable with water immersion for labor and birth are much more likely to have practice styles that minimize use of medical intervention and facilitate the unfolding of the physiologic process. To what extent, then, is water immersion simply a marker for this practice style?
The Take-Away
Let’s say you want the option of water immersion. Now what?
- If you’re planning a home birth and you don’t have a deep tub, talk to your midwife. She can likely help you with renting a portable birth pool.
- If you’re planning to birth at a freestanding birth center, that is, one that is independent of a hospital—some hospitals call their regular labor & delivery units “birth centers”—a birthing pool may be an amenity at the center, or, as with home births, they may be able to help you rent one.
- If you’re planning hospital birth, few U.S. hospitals offer immersion tubs or pools. A second-best is access to a shower, which may be easier to come by. As with warm water immersion we have data showing that showering reduces pain. I can also personally attest that standing under a warm shower in labor is soothing and relaxing. The problem with showering, though, may be caregiver or hospital routine policies or practices that prevent getting into a shower such as continuous fetal monitoring or having an IV. You may want to investigate your hospital’s and care provider’s standard management.
That brings me to my final point. If it is true that less use of medical intervention and improved outcomes have more to do with practice style than warm water immersion, you’ll reap those benefits regardless of whether you immerse in labor if you choose a care provider who practices physiologic care.
