The use of water during labor and birth has been used for many years in hospitals and birthing centers in the US and in many other parts of the world from Europe to China with comparable maternal and newborn outcomes whether or not they give birth in water. But the recent release of the Committee Opinion on “Immersion in Water During Labor and Delivery” in April 2014 by The American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics (AAP) suggests water may be beneficial during labor but questions the safety of water birth based on several rare case studies of newborns with serious adverse effects. The Opinion does not support water birth unless the facility is part of a research study. This Opinion has received much press and controversy. It is important for women at Dar a Luz to have the information available to make informed decisions about their care. We have included portions of key documents here and links to the full text for you to make your own informed decisions.
ACOG / AAP COMMITTEE OPINION: Immersion in Water During Labor and Delivery
“ABSTRACT: Immersion in water has been suggested as a beneficial alternative for labor, or delivery, or both and over the past decades has gained popularity in many parts of world. Immersion in water during the first stage of labor may be associated with decreased pain or use of anesthesia and decreased duration of labor. However, there is no evidence that immersion in water during the first stage of labor otherwise improves perinatal outcomes, and it should not prevent or inhibit other elements of care. The safety and efficacy of immersion in water during the second stage of labor have not been established, and immersion in water during the second stage of labor has not been associated with maternal or fetal benefit. Given these facts and case reports of rare but serious adverse effects in the newborn, the practice of immersion in the second stage of labor (underwater delivery) should be considered an experimental procedure that only should be performed within the context of an appropriately designed clinical trial with informed consent. Facilities that plan to offer immersion in the first stage of labor need to establish rigorous protocols for candidate selection, maintenance and cleaning of tubs and immersion pools, infection control procedures, monitoring of mothers and fetuses at appropriate intervals while immersed, and immediately and safely moving women out of the tubs if maternal or fetal concerns develop. “
ACOG & AAP Committee Opinion: Immersion in Water During Labor and Delivery. Retrieved from http://pediatrics.aappublications.org/content/133/4/758.full on April 17, 2014.
Many organizations that support women in birth including the American College of Nurse Midwives (ACNM), Waterbirth International and American Association of Birth Centers (AABC), have all weighed in on the topic. Each has issued a position statement reviewing the available research and citing the safety of immersion in water during labor and birth for selected women who are attended by experienced providers.
ACNM is the professional organization for nurse midwives and they have issued the “Position Statement: Hydrotherapy During Labor and Birth.” This statement discusses the available research and outlines evidence based practice for use of water during labor and birth. It states that:
“Labor and birth in water can be safely offered to women with uncomplicated pregnancies and should be made available by qualified maternity care providers. Labor and birth in water may be particularly useful for women who prefer physiological childbirth and wish to avoid use of pharmacological pain relief methods.”
ACNM Position Statement: Hydrotherapy During Labor and Birth. Retrieved from http://www.midwife.org/ACNM/files/ACNMLibraryData/UPLOADFILENAME/000000000286/Hydrotherapy-During-Labor-and-Birth-April-2014.pdf on April 17, 2014.
Waterbirth International: Barbara Harper’s opinion
Barbara Harper, founder of Waterbirth International (who is considered one of the world’s foremost experts in water birth research and education) has provided a summary in Science & Sensibility of her review of the research on water birth safety. This summary supports water birth as a safe and reasonable option for mothers and babies. It gives a good explanation of the research and how it was used in the ACOG Opinion.
In conclusion, she points out that “Water birth is an option for birth all over the world. World-renowned hospitals, as well as small hospitals and birthing centers, offer water birth as an option to low risk patients. Though some members of the American Academy of Pediatrics and American College of Obstetricians and Gynecologists feel otherwise, the Cochrane Review and many other studies find no data that supports safety concerns over water birth. Women increasingly are seeking settings for birth and providers that honor their ability to birth without intervention. Water birth increases their chances of attaining the goal of a calm intervention free birth. Physicians and midwives are skilled providers who are being trained in water birth techniques, safety concerns, the ability to handle complications and infection control procedures. Carefully managed, water birth is both an attractive and low-risk birth option that can provide healthy patients with non-pharmacological options in hospital facilities while not compromising their safety.”
Retrieved from http://www.scienceandsensibility.org/?p=8088 on April 17, 2014. “Why Pediatricians Fear Water birth – Barbara Harper Reviews the Research on Water birth Safety.”
The Cochrane Review: Immersion in Water in Labour and Birth
The Cochrane Review is a highly esteemed review of randomized controlled studies (RTCs). In February 2012 the “Immersion in Water in Labour and Birth” was published. This review includes 12 trials (3243 women): eight related to just the first stage of labour: one to early versus late immersion in the first stage of labour; two to the first and second stages; and another to the second stage only. We identified no trials evaluating different baths/pools, or the management of third stage of labour. The author’s conclusion states: “Evidence suggests that water immersion during the first stage of labour reduces the use of epidural/spinal analgesia and duration of the first stage of labour. There is limited information for other outcomes related to water use during the first and second stages of labour, due to intervention and outcome variability. There is no evidence of increased adverse effects to the fetus/neonate or woman from laboring in water or water birth. However, the studies are very variable and considerable heterogeneity was detected for some outcomes. Further research is needed.”
Cluett ER, Burns E. Immersion in water in labour and birth. Cochrane Database of Systematic Reviews 2009, Issue 2. Art. No.: CD000111. DOI: 10.1002/14651858.CD000111.pub3 – See more at: http://summaries.cochrane.org/CD000111/immersion-in-water-in-labour-and-birth#sthash.zUDf4Fhe.dpuf
Dar a Luz is a nationally Accredited Birth Center and participates in the AABC data collection. We feel that these data provide evidence of the safety of water birth. After analysis of these data, AABC has issued the “Position Statement: Immersion in Water during Labor and Birth.” These data demonstrate that water birth, with careful selection criteria and experienced providers, does not negatively affect mothers of newborns.
AABC Position Statement: Immersion in Water during Labor and Birth
The American Association of Birth Centers (AABC) member birth centers have read with concern the recently released ACOG/AAP Committee Opinion, “Immersion in Water during Labor and Delivery.” AABC agrees that published randomized controlled trials provide evidence demonstrating the benefits of immersion in water during the first stage of labor; however, the committee opinion does not reflect currently available best evidence for the use of water during second stage and for birth. Consequently, the document has the potential to introduce inappropriate fear about the safety of water birth for families, providers, facility administrators, insurers, and others who want to make informed decisions regarding immersion in water for labor and birth.
The AABC has collected and analyzed data on the use of water for labor and water birth from our online data registry, the AABC Uniform Data Set (UDS) (now Perinatal Data Registry).
Data for these analyses were collected from a sample of 15,574 obstetrically low-risk women eligible for birth center birth at the onset of labor from January 1, 2007 to December 31, 2010. There were 3998 water births in the sample; 57.6% were in birthing tubs, 34.6% were in Jacuzzis and 7.8% were in standard bathtubs, though outcomes did not differ across tub types.
These data demonstrate that water birth, with careful selection criteria and experienced providers, does not negatively affect mothers or newborns.
• Rates of postpartum and neonatal transfer from the birth center, and neonatal procedures were low for the sample in general, and were slightly lower for births in water when compared to non-water births. This has been reported elsewhere. 1
• This suggests that if labor is not progressing smoothly, women were unlikely to give birth in water and speaks to the importance of anticipatory and skilled water birth providers.
• Rates of newborn transfer to a hospital were lower following water birth (1.5%) than non-water birth (2.8%)
• Rates of adverse newborn outcomes (5 minute APGAR < 7, respiratory issues, presence of infection and NICU admission) were each below 1.0% in the water birth sample. The total rate of any respiratory issues was 1.6% in the babies born in water and 2.0% in those not born in water.
• There were no incidences of pneumonia, sepsis or other respiratory infection following water birth and there were no reports of ruptured umbilical cords or newborns breathing water into their lungs associated with birth underwater.
• Midwives practicing in birth centers are trained, anticipatory water birth providers, so data generated by midwifery care provides the most accurate view of the safety of water birth.
The claim that water birth is dangerous for mothers and babies is not based on prospective population data with skilled birth attendants, but on negative outcome case reports 2–8 or individual case outcomes reported in a large surveillance study from another country. 9 These reports have been used to support the position that water birth is unsafe for newborns and have received significant press. 10,11 However, many case reports include one or more water birth practices that violate published safe water birth criteria 12–14 (low-risk mothers, appropriate tub temperatures, planned with experienced practitioners), including inappropriately high tub temperatures for the mother and/or fetus 2, a long delay in bringing the newborn to the surface 4, bacterial infection following an birth in an unclean tub 3,6,15, accidental water birth 5, and unplanned water birth after an unplanned pregnancy. 8 Nonetheless, these case reports have been used to promote the use of water for labor only, and to discourage birth in water, citing fear of respiratory issues and infection. 10,11,16 This is an inappropriate use of these data. Instead, in the absence of well-designed RCTs, prospective data collected with anticipatory, skilled providers under safe water birth practices should be used in the informed consent process associated with water birth. These data do not show any difference in newborn outcomes between water birth and non-water birth. 12,14,17–19 In fact, as seen in the present data, there are no reports of serious newborn outcomes, newborn morbidity or mortality and any NICU admissions were typically resolved and discharged in 24 hours, but no more than 7 days. There are reports of umbilical cord rupture, but not at a rate higher than seen with non-water birth. 19 Childbearing families and others desiring accurate information about water birth deserve the very best available evidence that we can give them. To this end, AABC advocates:
1. Using the highest level of evidence available and providing this evidence to childbearing families to inform decision-making about water birth.
2. Including in the informed consent any gaps in available evidence regarding the safety of water birth.
3. Continuing to collect data on outcomes on immersion in water during second stage and for birth as used by anticipatory and skilled water birth providers.
1. Geissbühler, V. & Eberhard, J. [Experience with water births: a prospective longitudinal study of 9 years with almost 4,000 water births]. Gynakol. Geburtshilfliche. Rundsch. 43, 12–8 (2003).
2. Rosevear, S.K., Fox, R., Marlow, N. & Stirrat, G.M. Birthing pools and the fetus. Lancet 342,1048–9(1993).
3. Rawal, J., Shah, A., Stirk, F. & Mehtar, S. Water birth and infection in babies. BMJ309, 511(1994).
4. Rosser, J. Is water birth safe? The facts behind the controversy. MIDIRS Midwifery Dig. 4–6(1994).
5. Nguyen, S., Kuschel, C., Teele, R. & Spooner, C. Water birth –a near-drowning experience. Pediatrics110, 411–3(2002).
6. Soileau, S. L. et al. Case report: severe disseminated adenovirus infection in a neonate following water birth delivery. J. Med. Virol. 85, 667–9 (2013).
7. Kassim, Z., Sellars, M. & Greenough, A. Under water birth and neonatal respiratory distress. BMJ330, 1071–2(2005).
8. Dressler, J. et al. Neonatal fresh water drowning after birth in the bathroom. Am. J. Forensic Med. Pathol. 32,119–23 (2011).
9. Gilbert, R. E. & Tookey, P. A. Perinatalmortality and morbidity among babies delivered in water: surveillancestudy and postal survey. BMJ 319, 483–7 (1999).
10. Batton, D. G. et al. Underwater births. Pediatrics 115, 1413–1414 (2005).
11. American College of Obstetricians and gynecologists. Committee Opinion No. 594: Immersion in water during labor and delivery. Obstet. Gynecol. 123, 912–915 (2014).
12. Cluett, E. R. & Burns, E. Immersion in water in labour and birth. Cochrane Database Syst Rev CD000111 (2009). doi:10.1002/14651858.CD000111.pub3
13. Demirel, G., Celik, I. H., Erdeve, O. & Dilmen, U. Neonatal respiratory consequences from water birth in a tertiary centre. J. Paediatr. Child Health 49, E105–6 (2013).
14. Geissbühler, V. & Eberhard, J. Waterbirths: a comparative study. A prospective study on more than 2,000 waterbirths.
15. Fetal Diagn. Ther. 15, 291–300 (2000).15. Nagai, T. et al. Neonatal sudden death due to Legionella pneumonia associated with water birth in a domestic spa bath. J. Clin. Microbiol. 41, 2227–9 (2003).
16. Pinette, M. G., Wax, J. & Wilson, E. The risks of underwater birth. Am. J. Obstet. Gynecol. 190, 1211–5 (2004).
17. Zanetti-Dällenbach, R., Lapaire, O., Maertens, A., Holzgreve, W. & Hösli, I. Water birth, more than a trendy alternative: a prospective, observational study. Arch. Gynecol. Obstet. 274, 355–365 (2006).
18. Woodward, J. & Kelly, S. M. A pilot study for a randomized controlled trial of water birth versus land birth. BJOG 111, 537– 45 (2004).
19. Henderson, J. et al. Labouring women who used a birthing pool in obstetric units in Italy: prospective observational study. BMC Pregnancy Childbirth 14, 17 (2014). Approved by AABC Board of Directors: 4.1.2014
American College of Nurse Midwives
In January 2016, the American College of Nurse Midwives (ACNM) posted a story summarizing even more evidence that water birth is safe for mothers and newborns.
After reviewing the current research, opinions and position statements, Dar a Luz feels very comfortable continuing to offer low risk women the option to labor and birth in water. We have reviewed the research with our consulting physician and he agrees that we should continue offering immersion in water during labor and birth. Almost all of our mothers use water immersion during labor and the rate of water birth at Dar a Luz has been 64% over the past 6 years. We have had no adverse outcomes related to the use of water. During that time many mothers have experienced the benefits of immersion in water for labor and birth. These benefits include:
• Increased feeling of being calm, relaxed, nurtured, protected and in control, ease of movement
• Less painful contractions and less need for pain medications during labor
• Shorter labor and less need for increasing contractions during labor
• Baby benefits from an un-medicated mother with the full complement of hormones during labor and birth
• Higher rates of maternal satisfaction with childbirth
• No evidence demonstrates that immersion during labor affects rates of infection, length of pushing, type of delivery, perineal laceration incidence or severity, postpartum hemorrhage or postpartum depression.
• No relationship has been found between water during labor and abnormal fetal heart rate patterns, meconium stained amniotic fluid, umbilical cord blood pH values, newborn Apgar scores, infections, admissions to special care nurseries or rate of breastfeeding at 6 wks postpartum.
Use of water immersion for birth needs more study but current evidence suggests it is safe for women with uncomplicated pregnancies who are attended by experienced providers. The risks include:
• Maternal and fetal increased temperature and heart rate due to warm water
• Rare but potential waterborne infection of the newborn or mother
• Newborn respiratory problems. Rare but potential for aspiration of fluid resulting in drowning or pneumonia
• Rare cord avulsion (tearing of the cord) and risk of maternal and/or newborn hemorrhage
There are times when the use of water immersion during labor, birth or postpartum would be contraindicated. These include but are not limited to:
• Maternal fever
• Slow labor progress and need to evaluate contractions
• Abnormal fetal heart rate and need for closer evaluation
• Difficulty during pushing and need to evaluate progress
• Difficulty in removal of placenta, unstable mother or excessive bleeding after birth that needs evaluation
• At the discretion of the midwives
Dar a Luz follows evidence-based practices to minimize these risks.
• All midwives are trained and experienced in water birth.
• All low risk mothers are eligible for water birth. No exclusions for GBS positive or meconium stained fluid.
• Moms can regulate the water temperature to their own comfort and generally below 100 degrees.
• Maternal vital signs are assessed every 1-2 hours and fetal heart tones are taken every 5-30 minutes
• Baby is brought out of the water immediately and face is kept out of the water while the body is immersed to keep the baby warm and a blue chux pad is placed over the body to reduce heat loss.
• If the baby’s head is born out of the water, the head remains out of the water to avoid the risk of premature gasping under water.
• Close attention is given to the umbilical cord length after birth to reduce tension and risk for tearing.
• Strict procedures are followed to insure the tubs and any equipment used in the tub are either disposed of or thoroughly cleaned after every use to prevent infection