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Water Birth (Again)

Note: I had just finished writing this article when I discovered Dr. Jones had beat me to the punch with his March 28th article on the same subject. He did an excellent job, and of course reached the same conclusions I did (it’s not that great minds think alike, but that we base our conclusions on the same body of evidence). Rather than let my efforts go to waste, I decided to go ahead and publish my shorter, more idiosyncratic article. If it’s worth saying, it’s worth saying twice; and different approaches may appeal to different readers.


“Humani nihil a me alienum puto.”

Nothing human should be alien to me, and I can understand why people do most of the strange things they do, but water birth is something I have really had difficulty with. Why would anyone want a baby to be born underwater? Why would they want to buy a special pool, set it up in the living room, fill it with water, keep the water at the right temperature, and then have to deal with emptying the pool and cleaning up afterwards? I read about it and tried to understand, and now I have some insight into their reasons; but I think they are poor reasons, and the whole concept remains pretty alien to my mind.

The claims

I found a fuzzy feel-good rationale on the Waterbirth International website. Mothers feel it is the gentlest of gentle births. Warm, luxurious water cradles you and gives you complete freedom to move during the greatest achievement of your life. “The women who have experienced the support and comfort of water for their labors and held their newborns in their arms speak more than any scientific article or paper on the subject.” In other words, “We don’t need no stinkin’ science!”

They went on to make some specific claims of benefits:

  • Water facilitates mobility and allows the mother to assume a comfortable position
  • Speeds up labor
  • Reduces blood pressure
  • Gives mother more feelings of control
  • Provides significant pain relief
  • Promotes relaxation
  • Conserves energy
  • Reduces the need for drugs and interventions
  • Gives mother a private protected space
  • Reduces perineal trauma and eliminates episiotomies
  • Reduces C-section rates
  • Is highly rated by mothers and by “experienced providers”
  • Encourages an easier birth for mother and a gentler welcome for baby
  • Placing a pool of water in a birth room changes the atmosphere immediately. Voices get softer, everyone becomes less stressed
  • The easier movement with buoyancy helps open the pelvis
  • The body is less likely to secrete stress-related hormones and more likely to produce pain-relieving endorphins

The research

They said these benefits are supported by research. They didn’t provide any citations, so I consulted PubMed. Here’s what I found:

  • There have been only two randomized controlled trials of water birth vs. land birth. They found minimal benefit to the mother and no benefit to the baby.
  • A Cochrane review found a reduction in epidurals but no reduction in C-sections, assisted vaginal deliveries, or perineal trauma.
  • Another Cochrane review found a decrease in reported maternal pain with no effect on labor duration, operative delivery rate or neonatal outcomes.
  • Still another Cochrane review found no difference in the use of pain relief, duration of labor, meconium staining or perineal trauma.
  • A 2004 systematic review found 16 citations of adverse effects including drowning, neonatal hyponatremia, neonatal waterborne infectious disease, cord rupture with neonatal hemorrhage, hypoxemic encephalopathy and death.

In short, there was only one systematic review suggesting a decrease in epidurals and it was contradicted by another systematic review. There was no research to support any of the other claims. Even the reported decrease in epidurals is suspect because of confounders. These women had strong expectations of pain relief and were part of a culture that frowns on epidurals.

The history

I couldn’t help wondering who ever thought up the idea in the first place. I found this:

We tend to think of labouring in water as relatively new. However, a writer on water births, Janet Balaskas, says that’s not so. She describes legends [emphasis added] of South Pacific Islanders giving birth in shallow seawater and of Egyptian pharaohs born in water. In some parts of the world today, such as Guyana, in South America, women go to a special place at the local river to give birth. [Maybe they want ready access to water to wash away the blood and amniotic fluid. River water and sea water are cold, not warm. And why would anyone want to imitate legends or the practices of a few women from a pre-scientific culture?]

Giving birth in water (rather than labouring in it) is a relatively recent development in the Western world. The first water birth that we know about in Europe was in 1803 in France. A mother whose labour had been extremely long and difficult was finally helped to give birth in a tub of warm water. [Uncontrolled anecdotal evidence. How do we know she wouldn’t have given birth just as soon without the warm water?]

Expert opinion

A joint Committee Opinion from the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics says water birth is not recommended and should not occur outside the setting of a clinical trial due to the potential risks. You can read their whole report here.

Their conclusions:

Immersion in water during the first stage of labor may be appealing to some and 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. Immersion therapy during the first stage of labor should not prevent or inhibit other elements of care, including appropriate maternal and fetal monitoring.

In contrast, 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.

Although not the focus of specific trials, 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 protocols for moving women from tubs if urgent maternal or fetal concerns develop.

The Skeptical OB, Amy Tuteur, has stronger opinions. She considers water birth tantamount to delivering in a toilet. The water in the birthing tub will unavoidably become contaminated with skin and fecal bacteria. In fact, it is even worse than the water in a toilet because the warm environment promotes bacterial growth. The number of reported complications continues to rise; even deaths have occurred. The idea that the “diving reflex” will prevent babies from inhaling the water has been refuted. In compromised infants, the diving reflex is over-ridden and we know they can inhale thick meconium (essentially prenatal feces) in utero. Would you want to risk your baby inhaling toilet water?

Conclusion

Laboring in water offers minimal benefits if any, and delivering in water offers only risks without benefits. Patients who understand the science may still want to try it for their own personal fuzzy reasons, and I support patient autonomy as long as patients can give truly informed consent; but I suspect that most women who choose water birth are not adequately informed about the scientific evidence (or rather the lack thereof). And I wonder about the ethics. Mothers may have the right to reject science and believe that “The women…speak more than any scientific article or paper…,” but do they have the right to risk the health of their helpless infants?

Posted in: Obstetrics & gynecology

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