Water birth

Analgesia, analgesia during labor, balneotherapy for labor, birth under water, birthing tubs, childbirth, delivery, home birth, hydrotherapy, hydrotherapy for labor, labor, midwife, natural birth, saunas, tub.

Water birth is the practice of undergoing labor or delivery while immersed in a tub of warm water. The water birthing tub may be used only for the first stage of labor (from the onset of contractions to the point where the cervix is fully dilated or open) or it may be used throughout labor and delivery. Water birth is a type of hydrotherapy, or balneotherapy, which uses immersion in water to reduce pain or to treat an illness.

Water birth may have been practiced for centuries around the world. There are reports that Japanese women have labored in the sea and that Finnish women have given birth in saunas. There are legends of South Sea islanders giving birth in shallow seawater and of Egyptian pharaohs being born in the water. There are reports that Dr. Igor Charkovsky may have researched water birth in Russia during the 1960s. The French obstetricians Frederick Leboyer and Michel Odent used water immersion during birth in the late 1960s. It was originally used for infants as a transition to a womb-like environment. It was subsequently used for women in labor for pain control and for delivery. The practice became popular in the 1980s, often chosen by women wanting alternatives to lying on their backs in a horizontal position for childbirth, and it has been extensively documented and studied since that time.

Birthing tubs are available at many hospitals that provide water birth as an option to their obstetric patients. For home births, birthing tubs can be rented or purchased. It is recommended that a professional attendant with training in water birth be present during labor and delivery involving birthing tubs.

Water birthing has been reported to reduce the requirements for pain medicine in the first stage of labor and has not been associated with a significant increase in complications or negative outcomes for childbirth. Many women who have used this technique have reported positive experiences.

The Royal College of Obstetrics and Gynaecology (RCOG) in the United Kingdom has endorsed water birth as an option that women should have available to them for giving birth, provided that the professionals assisting them are familiar with the technique and that the equipment is handled and maintained properly.

Scattered water birth reports in the medical literature appeared starting in the 1960s. With water birth becoming a more common practice, many studies, some with more than 2,000 births, have been reported since that time.

One theory about the benefits of water birth put forth by advocates is that the baby has been in the water of the amniotic sac for nine months and that birth into a similar environment may be gentler for the baby and lessen the stress of the mother as well. Many practitioners believe that reducing the stress of the mother during labor and delivery decreases the potential for complications for the baby.

According to anecdotal reports and published studies, the birthing tub water may have relaxing and soothing effects for the mother.

The water provides buoyancy that relieves weight pressure, not only where the mother's body rests on the tub but also for the abdominal organs. This may promote better uterine contractions, blood circulation, and oxygenation for both the uterus and the fetus, according to advocacy groups, such as the American Pregnancy Association and Waterbirth International. These same groups also assert that immersion in water may help to lower high blood pressure in the mother and to reduce stress-related hormones, which may allow the mother to produce more pain-relieving endorphin hormones. There is a lack of published research that confirms these conjectures.

The water may relax the muscles of the floor of the abdomen (the perineum) so that there is a reduction in the tearing of the skin around the vagina, a reduction in the need for an intentional incision (episiotomy), and a reduction in the need for stitches.

Scientific studies of water birth have been difficult to conduct and to compare, as the definition of water birth can vary from using immersion for the first stage of labor only (from the onset of contractions to the point where the cervix is fully dilated or open) or throughout labor and delivery. As a result, there is some disagreement on the extent to which water birth has been demonstrated to be as safe as conventional labor and delivery.

The strongest evidence in support of water birth comes from an analysis of a number of human studies comparing any use of a bathtub or pool with no immersion in water during labor or birth. For the first stage of labor, there appears to be a significant reduction in the use of pain-control measures when immersed in water. This includes less use of local anesthetic, or numbing medicine, injected around the area of the spine, into the spinal canal, or around the cervix. There was no difference between using a bathtub or pool and using no immersion in water in terms of the need for the doctor to assist with the delivery by pulling the baby out. There was also no difference in rates of Cesarean section (C-section, or removing the baby through an incision in the mother's belly), in rates of damage or tears around the vagina, or in rates of infection in the mother. There were also no differences in rates of infection in the newborn, in rates of admission to special hospital units for newborns, or for the baby's immediate condition at birth, as measured by Apgar score. The Apgar score derives from five observations of the newborn for appearance (blue to pink), pulse rate, grimace or reflex irritability, activity or muscle tone, and breathing. Overall, an increase in negative outcomes for either the mother or the infant as a result of laboring or giving birth in water was not found.

Several studies on water birth have reported reduced needs for pain control interventions among mothers using a birthing tub for labor compared to those undergoing conventional labor. Mothers interviewed for these studies tended to describe the experience in positive terms.

Nurse-midwife practitioners surveyed about water birth have had generally positive attitudes towards the technique. They expressed reservations about water birth only in terms of concerns about maintenance of water temperature, physical stress on the midwife, and inability to see the perineum. The support of these midwives for water birth was focused mostly on the perceived benefits to the mother, including increased maternal relaxation and reduced use of pain medicine.

Some pediatricians and others have argued that water birth has been promoted by midwives and some physicians as a way to counter the "medicalization" of childbirth and return "empowerment" and "autonomy" to women. They recommend that informed consent be obtained by the practitioner and that expectant mothers and their families be informed of potential adverse outcomes that have been reported in the medical literature, including unexplained deaths; drowning and near-drowning; suffocation; excessive absorption of water by the infant, causing seizures; pneumonia in the infant; and brain damage from lack of oxygen. They also make the point that there is no reporting requirement for water birth in the United States and no central accrediting or regulating agency for institutions or practitioners.

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) does not evaluate centers or keep specific information on the practice of water immersion or water birth. There is no general agreement among practitioners about the conduct of water labor or water birth, including water-quality assessments, water depth or volume, and standards for assessment of mother and fetus, while there is a great deal of difference of opinion and practice. Critics of the practice advocate for improved recording of water labor and water births, including reliable reporting of negative events and outcomes, and suggest a compulsory central registry that would lead to an improved knowledge base and that would allow further studies and an eventual agreement on correct technique.

Despite notes of caution from academic physicians concerned about the inadequacy of the knowledge base and of the scientific human studies done so far, water birth has continued to become more widely available as an option and is likely to be an available option in the future.

This information has been edited and peer-reviewed by contributors to the Natural Standard Research Collaboration (www.naturalstandard.com).

American Pregnancy Association.

Cluett ER, Burns E. Immersion in water in labour and birth. Cochrane Database Syst Rev. 2009 Apr 15;(2):CD000111.

Geissb?hler V, Eberhard J. Waterbirths: a comparative study. A prospective study on more than 2,000 waterbirths. Fetal Diagn Ther. 2000 Sep-Oct;15(5):291-300.

Gilbert RE, Tookey PA. Perinatal mortality and morbidity among babies delivered in water: surveillance study and postal survey. BMJ. 1999 Aug 21;319(7208):483-7.

Meyer SL, Weible CM, Woeber K. Perceptions and practice of waterbirth: a survey of Georgia midwives. J Midwifery Womens Health. 2010 Jan-Feb;55(1):55-9.

Nagai T, Sobajima H, Iwasa M, et al. Neonatal sudden death due to Legionella pneumonia associated with water birth in a domestic spa bath. J Clin Microbiol. 2003 May;41(5):2227-9.

Natural Standard: The Authority on Integrative Medicine.

Odent M. Birth under water. Lancet. 1983 Dec 24-31;2(8365-66):1476-7.

Royal College of Obstetrics and Gynaecology (RCOG).

Rush J, Burlock S, Lambert K, et al. The effects of whirlpools baths in labor: a randomized, controlled trial. Birth. 1996 Sep;23(3):136-43.

Schroeter K. Water births: a naked emperor. Pediatrics. 2004 Sep;114(3):855-8.

During water birth, the pregnant woman enters a tub of warm water after labor has begun.

Some hospitals are equipped with water birthing tubs, and such tubs can also be purchased or rented for use at home. There are inflatable models for single use and multiple uses. Most practitioners do not advocate using the tub before labor, as that may contaminate the lining with bacteria. Popular books on the topic advocate a depth of water of at least 18 inches. Temperature can be monitored with a thermometer or adjusted to the mother's comfort but should be around 97 degrees Fahrenheit.

The water birthing tub may be used only for the first stage of labor (from the onset of contractions to the point where the cervix is fully dilated or open), or it may be used throughout labor and delivery. The mother is encouraged to use the tub as she is inclined to do so, and many mothers elect not to deliver while in the tub. Healthcare professionals recommend that a professional attendant with training in water birth be present during labor and delivery. A spouse, partner, or family member may be in attendance as well.

The buoyancy added by the presence of the water relieves the pressure of gravity on the woman's womb as well as on her pelvis. The water provides a covering that enhances the woman's sense of privacy and allows her to dispense with other drapery such as a sheet. The obstetrician or nurse-midwife may perform pelvic examinations while the mother is in the tub to gauge the progress of labor, or the mother may exit the tub and lie on a standard stretcher, gurney, or hospital bed for these examinations.

A water birth may take place in a home setting or in a hospital or clinic. A qualified healthcare provider should always supervise the process. Licensed or registered midwives, as well as obstetricians, are appropriate healthcare providers for this practice or technique. It is recommended that the practitioner have experience in assisting at water births. There is no specific licensing for the technique of water birth.