Active Birth Pools News

March 2022

New midwifery research and studies

Water birth in Sweden – a comparative study

Waterbirth in low-risk pregnancy: An exploration of women’s experiences

Water birth: a national retrospective cohort study of factors associated with its use among women in England

A systematic meta-thematic synthesis to examine the views and experiences of women following water immersion during labour and waterbirth

The perceptions and experiences of women who achieved and did not achieve a water birth

Midwives’ experience of their education, knowledge and practice around immersion in water for labour or birth

Factors influencing water immersion during labour: qualitative case studies of six maternity units in the United Kingdom

Labouring women who used a birthing pool in obsteric units in Italy: prospective observational study

An economic evaluation of water birth

February 2022

The Active II Water Birth Pool – innovative design makes our pools safer and more user-friendly 

Launch of the revolutionary Venus II Water Birth Pool

These pools are the same width as the original models but slightly longer and marginally more expensive.

Space and budget permitting I suggest you consider the Active and Venus II Water Birth Pools as your first choice.

They are game changers that make a real difference to the experience of all concerned.

January 2022

Launch of Resource and Educational Centre

A comprehensive collection of publications covering all aspects of water birth, design, build and setting up of a water birth facilities. A one of a kind resource that is the product of our 35 years of dedication to serving the needs of mothers and midwives.


Alternatively  – use the search field in the top right of the page to find the information you’re looking for.

December 2021

Active Birth Pool installed to create water birth facility in the Midriff Hospital in Dubai.

November 2021

“Freedom of Movement” now has over 11,000,000 views on YouTube

The simple, short video shows how mothers instinctively relate to our pools and move naturally to find the most comfortable, supportive and beneficial positions. Watch on YouTube



Educational Centre – for mothers, midwives, healthcare professionals, planners and builders

Right from the start we have made education an important part of who we are and what we do.

Browse through the categories below or use the search engine to find the information you’re looking for.

Water Birth Safety Initiative

Hospitals in the United Kingdom began allowing women to use specially designed pools of water for labour and birth during the 1980’s.

The wide-spread popularity and acceptance of water birth pools as a standard part of the maternity care package necessitated the development of guidelines & regulations to define standards and ensure they’re met.

The United Kingdom Department of Health has published a panoply of water safety directives that apply to water birth pools.

Policies and recommendations set forth in the Water Birth Safety Initiative are based upon these publications.

The Water Birth Safety Initiative (WBSI) calls for development of international standards modelled on the UK’s so that women the world over can benefit from the use of water for labour and birth safeguarded from risk.

The WBSI calls for the implementation of stricter protocols and sets forth recommendations for equipment standards.

The guidelines set forth in the WBSI are intended to serve as a framework of standards for birth pool suppliers, hospitals and midwives to work with to establish  safe codes of practice.

Guidelines for Water Birth Pools Installed in Hospital

Water is more prone to bacteria growth after it leaves the public water distribution system and enters a building’s plumbing.

There it finds warmer temperatures, stagnation, and smaller pipes, valves and fittings.

Biofilm that forms on valves and fittings and pipe walls not only feeds bacteria but also protects them from the hot water and chlorine that typically would kill free-floating organisms.

Large systems with complex piping networks — like those found in hospitals, hotels and large apartment buildings — are especially prone to bacteria growth.15

Water Birth Pools that are installed in hospitals have the benefit of being maintained by staff to ensure that protocols are established, met and maintained.

Consideration and due diligence with regard to the prospective purchase of water birth pools and the assessment of pools already in use needs to be taken to ensure that the associated plumbing and electrical systems meet relevant safety standards.

The United Kingdom’s Department of Health and National Health Service has an exemplary safety record achieved by establishing rigorous sets of guidelines and regulations for the design, installation, use and maintenance (cleaning/disinfection) of water birth pools.

In the UK water birth pools are classed as a Category Fluid 5 water risk which represents a serious health hazard due to the concentration of pathogenic organisms, radioactive or very toxic substances, e.g. containing faecal material or other human waste; butchery or other animal waste or pathogens.

Water Birth Pools must be installed in compliance with water regulations as set forth in The Water Supply (Water Fittings) Regulations 1999.11

The 7 sins of water safety

To ensure high standards are met it is strongly advised that you do not use a water birth pool that has any of these features:

  1. Overflow drains
  2. Internal water inlets
  3. Hand-held showers
  4. Systems with flexible hoses or extended pipes
  5. Integral or secondary plumbing systems
  6. Any type of recirculating or pumped water systems such as whirlpool, jacuzzi, spa, bubbling, filtering etc
  7. Heating systems

1) Overflow drains

Overflow drains harbour bacteria and can serve as a conduit for cross infection.

Regulations are very clear on this point – overflow drains should not be installed on water birth pools as they constitute a constant infection control risk much more significant than the possible risk of damage due to water overflowing.11,12

Some digital taps on the market can be set for filling time thus obviating the risk of the pool overflowing.

2) Internal water inlets

Internal water inlets act in place of taps to fill the pool.

They are installed on the inside of the pool just above the water line and connected with pipework to a thermostatic valve.

If the water level rises there is a high risk of back flow enabling bacteria to enter the system creating a risk of cross infection.7

3) Handheld showers

Handheld showers present a significant infection control risk due to the fact that they can fall in the pool and be contaminated with bacteria that could breed and be passed on next time the shower is used.

Department of Health regulations clearly stipulate that handheld showers and bath/shower mixers are not installed for use with water birth pools. 13

Handheld showers present a Fluid Category 5 risk to the mains water supply.

It must not be possible to submerge the showerhead in the water due to risk of cross infection.

In order to comply with category 5 water regulations covering back siphonage, a class AUK3 air gap would be required, which generally prevents the use of handsets, unless there is a separate break tank installed in the hospital plumbing system.

4) Systems with flexible hoses or extended pipes

Systems that employ flexible piping, have branch pipes or hold stagnant water present a potential hazard and must not be used with water birth pools.

It is impossible to clean, disinfect or monitor these systems.

They have been proven to be a source of Legionella and Pseudomonas. 14

Weekly flushing recommendations recommended by the department of health cannot be executed with such systems, and the effectiveness of this cannot be monitored due to the inacessibility of the closed system.

5) Integral or secondary plumbing systems

Integral, secondary or proprietary plumbing systems are fitted to some water birth pools.

As these systems can employ flexible and non-flexible piping, overflow drains, handheld showers and are often pumped or recirculating they present a significant infection control risk and should be banned from use.

Regulations stipulate that water birth pools are filled from thermostatically controlled wall mounted mixer taps plumbed directly into the hospitals water supply with the minimum of pipework.

Not only do secondary or integral plumbing systems present unacceptable risks, they are impossible to clean, disinfect or monitor and therefore present an extremely high and unacceptable infection control risk.

They must not be present on pools used for labour and birth. 10

6) Recirculating or pumped water systems

Recirculating or pumped water systems such as whirlpool, jacuzzi, spa, bubbling, filtering etc. have the perfect environmental conditions to be a potential source for the growth of microorganisms, including legionella bacteria and must not be installed on water birth pools.

Water systems that are able produce aerosols represent the highest levels of risk.

Aerosols can be generated very easily when the water surface is broken -for example, by falling water droplets, splashing, or by bubbles breaking at the surface.

Once introduced to artificial water systems, Legionella can thrive in warm water (30 – 35 °C) and has been shown to be present on flexible seals and metal surfaces within plumbing systems used in domestic potable water supplies.

Inadequately maintained spa pools (birth pools with pumped or recirculating systems) provide ideal conditions to support the growth of legionellae and other microorganisms, which may then become aerosolised and subsequently inhaled.15

7) Heating systems

Heating systems for water birth pools are not necessary and present unacceptable infection control risks.7

There are two types of heating systems in use:

1. Recirculating system with a heat exchanger

Water is pumped out of the pool and through a heat exchanger and then flows back into the pool.

These systems present one of the highest infection control risks and should not be installed on a water birth pool under any circumstances. (covered by points 4, 5 and 6 above).

2. Electric heating systems

Similar to under floor heating found in homes do not present an infection control risk.

But, they do present an unacceptable health and safety risk and should therefore not be installed in water birth pools.

These systems consist of a network of cables embedded in the fabric of the birth pool that are attached to the power supply through a thermostat.

The heat is transmitted from the cables through the floor of the pool and then transferred to the water.

The inherent problem with these systems is that the water is relied on to take the heat away from the material.

If a woman remains motionless the heat becomes concentrated and a “hotspot” develops which can result in the woman being burned.


Plumbing for filling and emptying water birth pools should be simple, straight forward and kept to the minimum.

A set of taps (see below) mounted on the wall 15cm above the rim and a drainage system similar to that of a normal bath is all that is required.

Rim mounted taps present two areas of risk:

1. Women may hit their head on taps that are mounted on the rim of the pool causing injury.

In the throes of labour a woman is not as cognisant of her surroundings as she normally is.

She needs to be protected from the potential harm that could result from hitting her head or other part of her body on the spout.

2. Risk to the taps and pool caused by the labouring woman grabbing onto the spout for support could easily cause damage to the fitting or fabric of the pool.

Filling the birth pool

Water Birth Pools should be filled directly from the hospitals main water supply through a ¾ Thermostatic Mixing Valve (TMV).

To comply with UK National Health Service regulations the valve must have TMV3 approval for use in Healthcare and Commercial situations and certify that it conforms to the performance requirements of the Department of Health.16

To kill legionella and other bacteria, water in hospitals systems is heated to 60 – 80 °C.

Water temperature entering the birth pool should be limited by the TMV to 44 °C to prevent scalding.

The added benefit of using a TMV connected directly to the hospitals main water supply is that it can be set to automatically flush itself of stagnant water twice a day and be thermally disinfected periodically.


The use of a TMV ensures a safe water supply.

Digital thermostatic mixing valves with enhanced thermal performance that incorporate these features are ideal:

1) Programmable control to accurately mix and maintain the temperature of the water flowing into the birth pool and limit the temperature of the water to 44 °C to prevent scalding.17

2) Programmable fill duration to fill the pool to the desired depth and then turn off.

This is important as water birth pools are not allowed to have overflow drains installed and this feature will prevent the pool from overflowing when unattended.

3) Programmable duty flushing to ensure that water does not stagnate within the tap and associated pipe work, effectively controlling the multiplication of legionella & other bacteria in infrequently used outlets.

Flushing duration is in line with HSE L8 recommendations.18

4) Programmable high-temperature thermal disinfection to destroy the proteins in viruses and bacteria and render them as dead or inert.

Thermal disinfection works by achieving a moist heat which is set at a specific temperature for a set amount of time.

Viruses and bacteria are very sensitive to heat and they will die if exposed to higher temperatures. 19

Emptying the Pool

Water from a birth pool needs to be treated as Fluid category 5 waste representing a serious health hazard due to the concentration of pathogenic organisms derived from fecal material or other human waste and emptied directly into the hospital’s waste water system.20

The pipework needs to have a trap or U bend fit as close to the waste/drain as possible.

The drainage fitting or waste should seal neatly into the drain.

The drainage fitting should be cleaned and flushed through with disinfectant and then dried as part of the cleaning protocol.

The waste should be kept closed when the pool is not in use.

There should be NO flexible pipe used in the drainage pipework.21

The waste should be remotely operated (i.e. pop up waste with rim mounted control) and of the best quality, preferably high-grade brass, to resist the corrosive action of chlorides and other disinfectants.


End notes

The Water Birth Safety Initiative was conceived by Keith Brainin to motivate and enable birth pool suppliers and health care professionals to raise standards and implement protocols to make water birth safe.


[1] Healio – Infectious Disease News. (2014, December 26). Legionellosis death after water birth sparks call for stricter infection control protocols. management/news/online/%7Bfe352169-755d-4d21-9bb2-abb8ae209f89%7D/legionellosis-death-after-water-birth-sparks-call-for-stricter-infection-control-protocols

[2] Inquisitr. (2015, January 16). Oregon Water Birth Leaves Baby Disabled, Lawsuit Wants Labor Options Banned.

[3] GOV.UK. Alert after Legionnaires’ disease case in baby, 2014.

[4] The Guardian. Legionnaires’ disease in baby is linked to heated birthing pool, June 17, 2014.

[5] Guidance from the  Water Regulations Advisory Scheme (WRAS)

[6] M.W. LeChevallier, 2003 World Health Organization (WHO). Conditions favouring coliform and HPC bacterial growth in drinking- water and on water contact surfaces. Heterotrophic Plate Counts and Drinking-water Safety. Edited by J. Bartram, J. Cotruvo, M. Exner, C. Fricker, A. Glasmacher. Published by IWA Publishing, London, UK. ISBN: 1 84339 025 6.

[7] Public Health England advice on home birthing pools, 2014.

[8] Health and Safety Executive. (2013). Legionnaires’ disease: Technical guidance [3.4], 2013.

[9] United Lincolnshire Hospitals NHS Trust UK. Cleaning, Disinfection and Sterilization Guidelines for Re-Usable Medical Devices 2010.

[10] Case of legionnaires’ disease in a neonate following an home birth in a heated birthing pool. England, June 2014

[11] Water Regulations Advisory Scheme (WRAS). Fluid Categories.

[12] WHBN 00-10 Welsh Health Building Note. Part C: Sanitary assemblies2014,

[13] Department of Health, Children, young people and maternity services. Health Building Note 09-02: Maternity care facilities, 2009.

[14] Freije, Matthew R. Some waterborne bacteria are tough, 2010.

[15] Woolnough, Kevin. Legionella Expert Calls for Greater Vigilance, 2014.

[16] BEAMA. TMV Standards and regulations, 2013.–air-movement/thermostatic-mixing-valves/tmva-faqs-on-thermostatic-mixing-valves/tmv-standards-and-regulations.cfm

[17] Health and Safety Executive. Managing the risks from hot water and surfaces in health and social care, 2012.

[18] Health and Safety Executive. Legionnaires’ disease The control of legionella bacteria in water systems, 2013.

[19] Health and Safety Executive. Managing legionella in hot and cold water systems.

[20] SMS Environmental – the water experts. Fluid Categories.

[21] Nottingham University Hospitals NHS Trust. Legionella Management and Control Procedures, 2014.


  • Ashford and St. Peter’s Hospitals, Women’s Health and Paediatrics Division (Abbey Birth Centre). Operational Policy and Clinical Guide, 2014.
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  • Buckinghamshire Healthcare NHS Trust. Water birth and use of water in labour guideline. Prod. Miss G Tasker and Audrey Warren. 2013.
  •  Dekker, Rebecca. “Evidence on the Safety of Water Birth.” 2014. (accessed 2014 10-09).
  • Department for Environment, Food and Rural Affairs. Water Supply (Water Fittings) Regulations 1999 Guidance Document relating to Schedule 1: Fluid Categories and Schedule 2: Requirements For Water Fittings. 1999.
  • Department of Health. Children, young people and maternity services Health Building Note 09-02: Maternity care facilities. 2009.

—. “Health Building Note 00-09: Infection control in the built environment.” 2002. (accessed 2014 6-12).

—. “Health Technical Memorandum 64: Sanitary assemblies.”  2006. (accessed 2014 10).

—. “Water systems Health Technical Memorandum 04-01: Addendum” .2013. (accessed 01 2014-10).

 —. “Water systems Health Technical Memorandum 04-01: The control of Legionella , hygiene, “safe” hot water, cold water and drinking water systems”. 2006.

  • DH, Estates & facilities. Water systems Health Technical Memorandum 04-01: Addendum . Department of Health, Department of Health.
  • Elizabeth R Cluett, Ethel Burns. Immersion in water in labour and birth. 2009. (accessed 2013 13-05).
  • Elyse Fritschel, Kay Sanyal, Heidi Threadgill, and Diana Cervantes. Emerging Infectious Diseases.CDC. Centers for Disease Control and Prevention. CDC. 2014. (accessed 2015 5-January).
  • Freije, Matthew R. Some waterborne bacteria are tough . 2010. (accessed 2015 20-01).
  • GOV.UK. Alert after Legionnaires’ disease case in baby. 2014. (accessed 2014 3-12).
  • GOV.UK. Public Health England advice on home birthing pools. 2014. (accessed 2014 03-August).
  • Healio – Infectious Disease News. Legionellosis death after water birth sparks call for stricter infection control protocols. 2014. (accessed 2015 07-01).
  • Health and Safety Executive. Legionnaires’ disease The control of legionella bacteria in water systems. 2013. (accessed 2014 07-07).

—. “Legionnaires’ disease: Technical guidance.”  2013. (accessed 2014 20-10).

—. Managing legionella in hot and cold water systems. (accessed 2015 07-01).

—. “Managing the risks from hot water and surfaces in health and social care.”  2012. (accessed 2014 20-11).

  •  Health Facilities Scotland. Consultation draft of SHTM 04-01 Water Safety for Healthcare Premises Part G: Operational Procedures and exemplar Written Scheme 2013. Health Facilities Scotland.
  •  Inquisitr. Oregon Water Birth Leaves Baby Disabled, Lawsuit Wants Labor Options Banned. 2015. (accessed 2015 16-01).
  •  Laura Franzin, Carlo Scolfaro, Daniela Cabodi, Mariangela Valera, and Pier Angelo Tovo. Legionella pneumophila Pneumonia in a Newborn after Water Birth: A New Mode of TransmissionOxford Journals, November 2001: 104.
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  •  M.W. LeChevallier, World Health Organisation. Conditions favouring coliform and HPC bacterial growth in drinkingwater and on water contact surfaces . 2003.
  •  N Phin, T Cresswell, F Parry-Ford on behalf of the Incident Control Team. CASE OF LEGIONNAIRES’ DISEASE IN A NEONATE FOLLOWING A HOME BIRTH IN A HEATED BIRTHING POOL, ENGLAND, JUNE 2014. 2014. (accessed 2015 10-01).
  •  Nottingham University Hospitals. LEGIONELLA MANAGEMENT AND CONTROL PROCEDURES. May 8, 2014.
  • Rosanna A. Zanetti-Daellenbach, Sibil Tschudin, Xiao Yan Zhong, Wolfgang Holzgreve, Olav Lapaire, Irene Ho ̈sli. Maternal and neonatal infections and obstetrical outcome in water birth . Prod. Women’s University Hospital Basel. Spitalstrasse, Basel: European Journal of Obstetrics & Gynecology and Reproductive Biology , 2006 28-August.
  • SMS Environmental – the water experts. Fluid Categories.
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  • Takuhito Nagai, Hisanori Sobajima, Mitsuji Iwasa, Toyonori Tsuzuki, Fumiaki Kura, Junko Amemura-Maekawa, and Haruo Watanabe. Neonatal Sudden Death Due to Legionella Pneumonia Associated with Water Birth in a Domestic Spa Bath. 2002. (accessed 2014 3-12).
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Please feel free to distribute and share this document crediting  © K. D. Brainin (Active Birth Pools) 2015

Immersion in water for labour and birth – Cluett and Burns

Enthusiasts suggest that labouring in water and waterbirth increase maternal relaxation, reduce analgesia requirements and promote a midwifery model of care.

Critics cite the risk of neonatal water inhalation and maternal/neonatal infection.


To assess the evidence from randomised controlled trials about immersion in water during labour and waterbirth on maternal, fetal, neonatal and caregiver outcomes.

Search methods—We searched the Cochrane Pregnancy and Childbirth Group’s Trials Register (30 June 2011) and reference lists of retrieved studies.

Selection criteria

Randomised controlled trials comparing immersion in any bath tub/pool with no immersion, or other non-pharmacological forms of pain management during labour and/or birth, in women during labour who were considered to be at low risk of complications, as defined by the researchers.

Data collection and analysis

We assessed trial eligibility and quality and extracted data independently. One review author entered data and the other checked for accuracy.

Main results

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.

Results for the first stage of labour showed there was a significant reduction in the epidural/spinal/ paracervical analgesia/anaesthesia rate amongst women allocated to water immersion compared to controls (478/1254 versus 529/1245; risk ratio (RR) 0.90; 95% confidence interval (CI) 0.82 to 0.99, six trials).

There was also a reduction in duration of the first stage of labour (mean difference −32.4 minutes; 95% CI −58.7 to −6.13).

There was no difference in assisted vaginal deliveries (RR 0.86; 95% CI 0.71 to 1.05, seven trials), caesarean sections (RR 1.21; 95% CI 0.87 to 1.68,eight trials), use of oxytocin infusion (RR 0.64; 95%CI 0.32 to 1.28,five trials), perineal trauma or maternal infection.

There were no differences for Apgar score less than seven at five minutes (RR 1.58; 95% CI 0.63 to 3.93, five trials), neonatal unit admissions (RR 1.06; 95% CI 0.71 to 1.57, three trials), or neonatal infection rates (RR 2.00; 95% CI 0.50 to 7.94, five trials).

Of the three trials that compared water immersion during the second stage with no immersion, one trial showed a significantly higher level of satisfaction with the birth experience (RR 0.24; 95% CI 0.07 to 0.80).

A lack of data for some comparisons prevented robust conclusions. Further research is needed.

Authors’ conclusions

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 labouring in water or waterbirth.

However, the studies are very variable and considerable heterogeneity was detected for some outcomes.

Further research is needed.

Click here for PDF of the full study






Michel Odent – the birthing pool test

This article first appeared in Midwifery Today, Issue 115, Autumn 2015.

There are many reasons to avoid last-minute cesarean sections that are decided at a phase of real emergency.

They are usually preceded by signs of fetal distress and they are often performed in poor technical conditions.

Furthermore, they are associated with negative long-term outcomes.

For example, according to an American study, women with a full-term second stage cesarean have a spectacular increased rate of subsequent premature births (13.5%) compared to a first-stage cesarean (2.3%) and to the overall national rate (7–8%) (Levine et al. 2014).

There are also serious reasons to avoid prolonged pharmacological assistance during labor, since the probable long-term effects of its different components (particularly drips of synthetic oxytocin) have never been evaluated through valuable scientific studies.

When a woman enters the pool in hard labor, there is an immediate pain relief, and therefore an immediate reduction in the levels of stress hormones.

Since stress hormones and oxytocin are antagonistic, the main short-term response is usually a peak of oxytocin and therefore a spectacular progress in the dilation.

We must add reasons to avoid, when it is possible, prelabor cesareans.

Apart from impaired lung maturation, it appears that the state of stress deprivation associated with “birth without labor” has a great variety of effects on the child, such as a lack of maturation of its olfactory sense (Varendi, Porter and Winberg 2002), which is a guide towards the nipple as early as the hour following birth (Odent 1977; Odent 1978).

Low levels of specific informational substances in the blood of stress-deprived neonates suggest effects on metabolic pathways and development of certain brain structures (Hermansson, Hoppu and Isolauri 2014; Simon-Areces et al. 2012).

It appears also that the milk microbiome and the gut flora of infants are disturbed in a specific way after birth by prelabor cesareans (Azad et al. 2013; Dogra et al. 2015), which is the mode of medicalized birth that disturbs breastfeeding more than all others (Prior et al. 2012; Zanardo et al. 2012).

Unexpectedly, it has been revealed recently that the risk of placenta previa in subsequent pregnancies is statistically significant only if the cesarean has been performed before the labor starts (Downes et al. 2015).

Finally, we are reaching a phase in the history of midwifery and obstetrical practices when an in-labor non-emergency cesarean appears in many cases as the best alternative to drugless childbirth.

In such a context, we understand the need for a new generation of tests in order to decide early enough during labor that the vaginal route is acceptable, without waiting for the phase of real emergency (Odent 2004).

The Basis for the Birthing Pool Test

The birthing pool test is the typical example of a tool adapted to futuristic strategies. It is based on a simple fact.

When a woman in hard labor enters the birthing pool and gets immersed in water at the temperature of the body, a spectacular progress in the dilation is supposed to occur within an hour or two.

If the already well-advanced dilation remains stable in spite of water immersion, privacy (no camera!) and dim light, one can conclude that there is a major obstacle. There is no reason for procrastinations. It is wiser to perform right away an in-labor non-emergency cesarean.

In the early 1980s, I had already mentioned in a mainstream medical journal (Odent 1983) the reason why we originally introduced the concept of birthing pools in the context of a French state hospital.

I had also described the most typical scenario: “We tend to reserve the pool for women who are experiencing especially painful contractions (lumbar pain, in particular), and where the dilatation of the cervix is not progressing beyond about 5 cm. In these circumstances, there is commonly a strong demand for drugs.

In most cases, the cervix becomes fully dilated within 1 or 2 hours of immersion…” At that time, I could only refer to most cases.

Afterwards, I analyzed the outcomes in the rare cases when the dilation had not progressed after an hour or two in the bath. I realized that finally a cesarean had always been necessary, more often than not after long and difficult first and second stages.

This is how I started to tacitly take into account what I had not yet called the birthing pool test.

More recently it happened that I mentioned the birthing pool test during information sessions for doulas.

This is how I learned from a series of reports about births in London hospitals.

It is obvious that many long and difficult labors with the usual range of drugs preceding an emergency cesarean would be avoided if the birthing pool test had been interpreted.

One of these anecdotes is particularly significant.

A woman in hard labor arrived in a maternity unit with her doula while the dilation of the cervix was already well advanced.

Soon after, she entered the birthing pool.

More than an hour later, the dilation had not progressed.

The doula, who was aware of the birthing pool test, was adamant that this woman could not safely give birth by the vaginal route.

A senior doctor was eventually called and diagnosed a brow presentation.

A brow presentation is difficult to diagnose in early labor and is incompatible with the vaginal route. In this case, the doula knew that a cesarean would be necessary, although she could not explain why.

The birthing pool test implies that an internal exam has been performed just before immersion so that, if necessary, a comparison will become possible after an hour or two.

This is an important practical detail, because midwives who are familiar with undisturbed and unguided births in silence, semi-darkness and privacy usually can follow the progress of labor with other criteria than a repeated evaluation of the dilation of the cervix.

Today, we can offer a physiological scenario explaining why immersion in warm water (set to the temperature of the body) makes the contractions more effective during a limited period of time.

When a woman enters the pool in hard labor, there is an immediate pain relief, and therefore an immediate reduction in the levels of stress hormones.

Since stress hormones and oxytocin are antagonistic, the main short-term response is usually a peak of oxytocin and therefore a spectacular progress in the dilation.

After that, there is a long-term complex response, which is a redistribution of blood volume.

This is the standard response to any sort of water immersion.

There is more blood in the chest (Norsk and Epstein 1988).

When the chest blood volume is increased, certain specialized cells in the atria release a peptide commonly called ANP (atrial natriuretic peptide) that interferes with the activity of the posterior pituitary gland (Gutkowska, Antunes-Rodrigues and McCann 1997).

We can all observe the effects of a reduced activity of our posterior pituitary gland after being in a bath for a while: we pass more urine.

This means that the release of vasopressin—a water retention hormone—is reduced.

In fact, the chain of events is not yet completely clarified (Mukaddam-Daher et al. 2002).

We have recently learned that oxytocin—the love hormone—has receptors in the heart (!) and that it is a regulator of ANP (Gutkowska et al. 1997).

In practice, we need to remember that the immediate peak of oxytocin following immersion in warm water will induce a feedback mechanism and eventually the uterine contractions will become less effective after an hour or two.


  • Azad, MB, et al. 2013. “Gut Microbiota of Healthy Canadian Infants: Profiles by Mode of Delivery and Infant Diet at 4 Months.” CMAJ 185 (5): 385–94.
  • Dogra, S, et al. 2015. “Dynamics of Infant Gut Microbiota Are Influenced by Delivery Mode and Gestational Duration and Are Associated with Subsequent Adiposity.” MBio 6 (1): e02419–14.
  • Downes, KL, et al. 2015. “Previous Prelabor or Intrapartum Cesarean Delivery and Risk of Placenta Previa.” Am J Obstet Gynecol 212 (5): 669 e1–6.
  • Gutkowska, J, J Antunes-Rodrigues and S McCann. 1997. “Atrial Natriuretic Peptide in Brain and Pituitary Gland.” Physiol Rev 77 (2): 465–515.
  • Gutkowska, J, et al. 1997. “Oxytocin Releases Atrial Natriuretic Peptide by Combining with Oxytocin Receptors in the Heart.” Proc Natl Acad Sci USA 94 (21): 11,704–09.
  • Hermansson, H, U Hoppu and E Isolauri. 2014. “Elective Caesarean Section Is Associated with Low Adiponectin Levels in Cord Blood.” Neonatology 105 (3): 172–74.
  • Levine, LD, et al. 2014. “Does Stage of Labor at Time of Cesarean Affect Risk of Subsequent Preterm Birth?” Am J Obstet Gynecol 212 (3): 360 e1–7.
  • Mukaddam-Daher, S, et al. 2002. “Regulation of Cardiac Oxytocin System and Natriuretic Peptide during Rat Gestation and Postpartum.” J Endocrinol 175 (1): 211–16.
  • Norsk, P, and M Epstein. 1985. “Effects of Water Immersion on Arginine Vasopressin Release in Humans.” J Appl Physiol 64 (1): 1–10.
  • Odent, Michel. 1977. “The Early Expression of the Rooting Reflex.” In Proceedings of the 5th International Congress of Psychosomatic Obstetrics and Gynaecology, Rome 1977. 1117–19. London: Academic Press.
  • ———. 1978. “L’expression précoce du réflexe de fouissement.” In Les cahiers du nouveau-né, vol. 1–2, edited by E Herbinet. 169–85. Paris: Stock.
  • ———. 1983. “Birth Under Water.” Lancet 2 (8365–66): 1476–77.
  • ———. 2004. The Caesarean. London: Free Association Books.
  • Prior, E, et al. 2012. “Breastfeeding after Cesarean Delivery: A Systematic Review and Meta-analysis of World Literature.” Am J Clin Nutr 95 (5): 1113–35.
  • Simon-Areces, J, et al. 2012. “UCP2 Induced by Natural Birth Regulates Neuronal Differentiation of the Hippocampus and Related Adult Behavior.” PLoS ONE 7 (8): e42911.
  • Varendi, H, RH Porter and J Winberg. 2002. “The Effect of Labor on Olfactory Exposure Learning within the First Postnatal Hour.” Behav Neurosci 116 (2): 206–11.
  • Zanardo, V, et al. 2012. “Impaired Lactation Performance Following Elective Delivery at Term: Role of Maternal Levels of Cortisol and Prolactin.” J Matern Fetal Neonatal Med 25 (9): 1595–98.


A landmark in the history of water birth – Michel Odent

August 21, 1999 should be remembered as a landmark in the history of water birth.

On that day the British Medical Journal published an unprecedented study about “the perinatal mortality and morbidity among babies delivered [sic] in water” (1).

This study is authoritative for several reasons:

  • The conclusions are based on large numbers: the authors traced the 4,032 babies born
    under water in England and Wales between April 1994 and March 1996.
  • The authors belong to a prestigious department of epidemiology and public health
    (Institute of Child Health, London, United Kingdom).
  • The report has been published in a respected peer review medical journal.


In order to convince anyone of the seriousness of this study, all midwives should be aware of the sophisticated methods used by the London epidemiologists.

Several inquiries were combined in order to eliminate the effects of under-reporting.

From April 1994 to April 1996, all 1,500 consultant pediatricians in the British Isles were surveyed each month by the “British Paediatric Surveillance Unit” and asked to report whether or not they knew of any births that met the case definition of “perinatal death or admission for special care within 48 hours of birth following labour or delivery in water.”

The findings were compared with reports to the confidential inquiry into stillbirths and death in infancy (a mandatory notification scheme).

At the same time a postal questionnaire was sent to all National Health Service (NHS) maternity units in England and Wales in 1995 and again in 1996 to determine the total number of deliveries in water during the study period.


The main results can be easily summarized and remembered.

There were five perinatal deaths among 4,032 births in water; that is a rate of 1.2 per 1,000. In the context of the United Kingdom this rate is similar for low risk deliveries that do not take place in water.

Furthermore, none of these five deaths were attributable to delivery in water: one stillbirth was diagnosed before immersion; another stillbirth occurred after a concealed pregnancy and unattended homebirth with no previous prenatal care; one baby died aged three days with neonatal herpes infection; one died aged thirty minutes with an intracranial hemorrahage after precipitate delivery; and another one, who died aged eight hours, was found to have hypoplastic lungs at postmortem examination.

There were thirty-four babies admitted for special care; that is a rate of 8.4 per 1,000.

Rates of admission for special care of babies born to low risk primiparous women are significantly higher than for babies born in water.

Birth in water may have caused water aspiration in two babies.


Compared with well known anecdotes, such as one case of neonatal polycythemia reported in The Lancet in 1997(2), this survey of more than 4,000 babies born (rather than delivered!) in water has been paradoxically ignored by the media, the medical circles and the natural childbirth movement as well.

However, it undoubtedly represents a landmark in the history of the use of water during labour.

From now on midwives should not be the prisoners of strict protocols.

Updated flexible guidelines should accept that “in any hospital where a pool is in daily use a birth under water is bound to happen now and then”(3).

Midwives are far less anxious and invasive wherever a birth under water is considered acceptable if the woman does not have the time or is reluctant to get out of the water during a powerful “fetus ejection reflex.”

The first effect of this study should be to change the focus.

An opportunity is given to recall that the main reason for the birthing pools is to facilitate the birth process and to reduce the need for drugs and other intervention.

In order to control the current epidemic of epidurals the point is to divulge a small number of simple updated recommendations in order to make the most effective use of birthing pools.

Updated recommendations

The main recommendations are based on the fact that immersion in water at the temperature of the body tends to facilitate the birth process during a limited length of time (in the region of an hour or two).

This simple fact is confirmed by clinical observation and by the results of a Swedish randomised controlled study suggesting that women who enter the bath at five centimetres or after (“late bath group”) have a short labour and a reduced need for oxytocin administration and epidural analgesia (4).

Physiologists can offer interpretations.

The common response to immersion is a redistribution of blood volume (more blood in the chest) that stimulates the release by specialized heart cells of the atrial natriuretic peptide (ANP).

The inhibitory effect of ANP on the activity of the posterior pituitary gland is slow, in the region of one to two hours (5).

When a woman is in labour this inhibitory effect is preceded by an analgesic effect that is associated with lower levels of stress hormones and increased release of oxytocin.

Furthermore it is partly via a release of oxytocin that the redistribution of blood volume stimulates the specialized heart cells.

The first practical recommendation is to give great importance to the time when the laboring woman enters the pool.

Experienced midwives have many tricks at their disposal to help women be patient enough so that they can ideally wait until five centimetres dilation.

A shower, that more often as not implies complete privacy, is an example of what the midwife can suggest while waiting.

The BMJ survey clearly indicates that many women stay too long in the bath (the average time was in the region of three hours for women who gave birth in water!).

One reason is that many of them enter the bath long before five centimetres.

The second recommendation is to avoid planning a birth under water.

When a woman has planned a birth under water she may be the prisoner of her project; she is tempted to stay in the bath while the contractions are getting weaker, with the risk of long second and third stages.

There are no such risks when a birth under water follows a short series of irresistible contractions.

The recommendations regarding the temperature should not be overlooked.

It is easy to check that the water temperature is never above 37° C (the temperature of the maternal body).

Two cases of neonatal deaths have been reported after immersion during labor in prolonged hot baths (39.7° C in one case) (6).

The proposed interpretation was that the fetuses had reached high temperatures (the temperature of a fetus is 1° higher than the maternal temperature) and could not meet their increased needs in oxygen.

The fetus has a problem of heat elimination.

At the dawn of a new phase in the history of childbirth one can anticipate that, if a small number of simple recommendations are taken into account, the use of water during labor will seriously compete with epidural anesthesia.

Then helping women to be patient enough and enter the pool at the right time will appear as a new aspect of the art of midwifery.

Michel Odent, MD founded the Primal Health Research Centre in London and developed the maternity unit in Pithiviers, France, where birthing pools are used. He is the author of ten books published in twenty languages. Two of them—Birth Reborn and The Nature of Birth and Breastfeeding—were published originally in the United States. His most recent book is The Caesarean.



Research offers reassurance for expectant mothers considering a water birth

Giving birth in water is associated with a reduced risk of excessive bleeding and perineal tearing for mothers and with babies born in water being less likely to need specialist care, a new study has found.

In a paper co-authored by De Montfort University Leicester (DMU)’s Dr Tina Harris and published by the BMC Pregnancy & Childbirth journal, researchers showed that the likelihood of key maternal and neonatal complications associated with waterbirths was low.(Image: Hu Chen/Unsplash)

The observational study, which involved an analysis of 46,088 low and intermediate risk vaginal births across 35 NHS Trusts in England, showed that 6,264 (13.6%) were recorded as delivering their baby in the water.

Of those 6,264 babies born, the research highlighted that there was no association between waterbirth and specific adverse outcomes for either the mother or the baby.

More specifically, the paper outlines there was no association between those women who chose to give birth in water and four common concerns, including:

  • Severe perineal tear for mothers
  • Excessive bleeding for mothers
  • Babies born with a low Apgar score (the Apgar score is a test given to newborns soon after birth to check a baby’s heart rate, breathing, and other signs to see if extra medical care or emergency care is needed)
  • Babies requiring neonatal care after birth.

“Immersion in water during labour is associated with a number of maternal benefits however for birth in water the situation is less clear,” explained Dr Harris, who is an active researcher at DMU’s Centre for Reproduction Research.

“While we can’t say there is no associated risk, what we can report from this study is that the association with each of these concerns and waterbirths is a positive one.

“These are four common birthing factors that expectant mothers may be concerned about and we found an association of reduced risk for all four.”

The research provides further evidence for NICE (The National Institute for Health and Care Excellence) on risks associated with waterbirths.

The study also explored the characteristics of those women who gave birth in water and found that women living in deprived areas are half as likely to have a water birth than those living in affluent areas and that younger women and women from black and minority ethnic backgrounds were also less likely to have a waterbirth.

“Most NHS Trusts do have a birthing pool  so all women should have access to giving birth in water, but our study has revealed that some women, from socially deprived areas and from the BAME community, are less likely to have a waterbirth. So we want to understand why that is,” continued Dr Harris.

“Hopefully this research will give women more information and reassurance to help them with their decision on whether or not to have a waterbirth. It’s important that pregnant women have access to as much information as possible to make an informed choice.”

As well as being an Associate Professor in the Faculty of Health and Life Sciences at DMU, Dr Harris is also a registered midwife with an NMC (Nursing and Midwifery Council)-recognised teaching qualification and in 2016, she was appointed Senior Clinical Lead (Midwifery) for the National Maternity and Perinatal Audit at the Royal College of Obstetrics and Gynaecology.

Posted on Friday 4th June 2021

Joint statement: Immersion in water during labour and birth – RCOG RCOM

Royal College of Obstetricians and Gynaecologists/Royal College of Midwives

Joint statement No.1 Immersion in water during labour and birth

Originally published: 2006


1.  Both the Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives support labouring in water for healthy women with uncomplicated pregnancies.

The evidence to support underwater birth is less clear but complications are seemingly rare.

If good practice guidelines are followed in relation to infection control, management of cord rupture and strict adherence to eligibility criteria, these complications should be further reduced.


  1. Lying in warm water gives a sense of relaxation, but whether it actually reduces pain is less certain. A perception of relaxation, pain relief, ease of movements and more holistic experience made labour in water a popular choice during the 1980s. This concept has been extended to include actual birth under water following widely quoted experience from France.1 In response to public demand, the Winterton Report recommended that all maternity services provide women with the option to labour and/or give birth in water.2
  2. Recent surveys3 show that, of 295 UK maternity units for which data on birthing pools were available, 64% had at least one birthing pool, with 20 units having two or more. There are no current data on the number of women who actually use these facilities during labour or for water birth, apart from a postal survey carried out between April 1994 and March 1996, which reported that, at that time, fewer than 1% of births in England and Wales occurred in water.4
  3. Partly in response to the Winterton Report, the Royal College of Obstetricians and Gynaecologists produced a Statement on birth in water in 1994, which was updated in 20015 and the Royal College of Midwives published a Position Paper on the use of water in labour and birth in 1994 (updated in 2000).6 Both documents endorsed the use of water in labour as a choice, provided that attendants had appropriate skills and confidence to assist women who choose to labour or give birth in water.

Labouring in water

  1. It is important to separate the evidence on benefits and risks of immersion in water during the active phase of labour from those of actual birth in water.
  2. There are considerable perceived benefits of using immersion in water during labour, including less painful contractions and less need for pharmacological analgesia, shorter labour, less need for augmentation, with no known adverse effects for the woman herself.However, there may be rare but clinically significant risks for the baby born under water. These include respiratory problems (including the possibility of fresh water drowning), cord rupture with haemorrhage, and waterborne infections.
  1. A Cochrane review by Cluett et al.7 provides the most recent evidence on water births. Overall, there was no difference found in the use of analgesia, although women allocated to immersion in water needed less epidural, spinal or paracervical analgesia. There was no significant difference in other important clinical outcomes, including duration of labour, operative delivery and perineal trauma. The same applied to the neonatal outcomes, including neonatal infection, which was rare.
  2. The evidence on timing of immersion into water during the first stage of labour was not robust enough to set criteria8 but early labour could be managed by mobilisation and other activities within a labour room rather than water immersion.
  3. Most of the available evidence, both randomised and observational, is restricted to healthy women with uncomplicated pregnancy at term, although induction of labour and previous caesarean section have been managed using water for labour and birth without reported problems.9 A randomised trial by Cluett et al.10 on women with prolonged labour found reduction in obstetric intervention following immersion in water but a higher number of babies who needed admission to the neonatal unit. Although there is clearly a need for more research, the currently available evidence does not justify discouraging women from choosing immersion in water during labour. Increasing women’s choices for analgesia and the need for maternity services to promote normality are key principles in all UK Maternity Service Framework documents and support provision of birthing pools to be made available for healthy women with uncomplicated pregnancies.11–13

Birth in water

  1. Informed choice on the benefits and risks of birth in water is clouded by the lack of good quality safety data. Although there is no evidence of higher perinatal mortality or admission to special care baby units (SCBUs) for birth in water,4,14,15 caution is advised because of small numbers, possible under-reporting of SCBU admission and exclusion of women who were in labour in water but gave birth conventionally after complications.
  2. One review identified 16 articles reporting a total of 63 neonatal complications attributable to water birth, including drowning, respiratory problems, cord avulsion and waterborne infections.16 One can argue that this anecdotal evidence is reassuring, given the thousands of women who have given birth under water in the last few decades. However, we still do not know how the low perinatal mortality and morbidity rates compare with those babies born in air.
  3. The respect for maternal autonomy and choice is important; however, it is important that any possible concerns for fetal and neonatal safety are made clear. Women who make an informed choice to give birth in water should be given every opportunity and assistance to do so by attendants who have appropriate experience. More research is needed on third-stage management in the pool, as there is currently no reliable evidence that can be used to inform women regarding the benefits and risks of experiencing the third stage of labour under water.

Achieving best practice

13 Both the Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives believe that to achieve best practice with water birth it is necessary for

Royal College of Obstetricians and Gynaecologists and Royal College of Midwives Joint Statement No.1 2 of 5 organisations to provide systems and structures to support this service.

This means developing a service that is committed to responsive practices and ensuring that women are involved in planning their own care with information, advice and support from professionals.11–13

Inclusion and exclusion criteria

14 All healthy women with uncomplicated pregnancies at term should have the option of water birth available to them and should be able to proceed to a water birth if they wish. The written documentation of any discussion is essential.

Practice issues

  1. There has been much controversy over the temperature of the water of a birthing pool, with strict criteria recommending differing estimates ranging from 34 to 37 degrees Celsius17 to a Swedish study which recommended that women be encouraged to regulate the temperature of the water to suit themselves.18 Given these large discrepancies, it would be difficult to agree strict temperature restrictions. It may be of more benefit to allow women to regulate the pool temperature to their own comfort and encourage them to leave and re-enter the pool in the first stage of labour as and when they wish. Birth attendants should ensure that the ambient room temperature is comfortable for the woman and should encourage her to drink to avoid dehydration. Cord clamps should be readily available and birth attendants need to be alert to the possibility of occult cord rupture and be sensitive to any undue tension on the cord.16
  2. Monitoring of the fetal heart using underwater Doppler should be standard practice, as stated in the current National Institute for Health and Clinical Excellence guidelines.19 If there are any concerns about maternal or fetal wellbeing, the woman should be advised to leave the birthing pool and an opinion from an obstetrician or other suitably qualified person should be sought in the usual manner. There needs to be a locally agreed procedure for getting a woman out of the pool, should she become compromised, and all staff likely to be caring for the woman in the room must be familiar with the procedure and should practice it regularly in emergency drills.
  3. If the woman raises herself out of the water and exposes the fetal head to air, once the presenting part is visible, she should be advised to remain out of the water to avoid the risk of premature gasping under water.
  4. All birthing pools and other equipment (such as mirrors and thermometers) should be disposed of or thoroughly cleaned and dried after every use, in accordance with local infection control policies. Disposable sieves should be made available to ensure that the pool remains free from maternal faeces and other debris. Local information and guidelines regarding prevention of legionella build up in water supply from seldomly used pools should be obtained from local NHS trust estates and should be adhered to. Midwives should use universal precautions and follow local trust infection control guidelines.

Education, skills and training

19 Midwives should discuss antenatally the use of immersion in water in labour with all women in a low-risk category, as part of their overall discussions regarding options for pain relief, and information leaflets should be available. It is important that information on water birth is conveyed to all women in a form they can understand and in a culturally sensitive fashion, to ensure parity of access to quality services.

Royal College of Obstetricians and Gynaecologists and Royal College of Midwives Joint Statement No.1 3 of 5

  1. All midwives should ensure that they are competent to care for a woman who wishes to have a water birth and have a good understanding of the basic principles of caring for a woman in labour, and should make themselves aware of local policies and guidelines. Apart from emergency drills, training should also include emergency management of cord rupture at birth.20
  2. Midwives, managers and supervisors of midwives should ensure that training in caring for a woman who wishes to have a water birth is undertaken by midwives who undertake intrapartum care, in order to increase choice for women and promote normality and ensure quality care.11,21,22


  1. The use of birthing pools for labour and birth should be audited carefully. Data should be kept both on immersion in first stage of labour for analgesia use and separately for underwater birth. Data collected should focus on maternal wellbeing and the condition of the baby at birth, and should include usual birth outcomes, incidence of cord rupture and reasons for and rates of neonatal admission to SCBU.
  2. Data should also identify women who wanted a water birth but were transferred to conventional birth, including decision time to leave the pool for the birth of baby, the reasons for transferring to conventional care and the condition of mother and baby at transfer.
  3. Data should also be collected on women who wished to use the birthing pool but for whatever reason were unable to do so. Units should also audit ethnicity in relation to the offer of the option of water birth, to ensure that there is parity of access.

Record keeping

25 Accurate contemporaneous records should be kept, as usual. In addition, times of entering and leaving the pool should be clearly documented, including the reason for leaving the pool, if appropriate. It is important that it is recorded clearly whether the baby was born under water.

User surveys

26 User surveys of satisfaction with water birth services, including ease of access and the quality of the information given, should be carried out. Cultural acceptability needs to be reviewed to ensure equity of access and culturally sensitive services.


  1. Odent M. Birth under water. Lancet 1983;2:1476–7.
  2. House of Commons Health Committee. Second Report on the Maternity Services (Winterton report). London: HMSO; 1992.
  3. Dr Foster Good Birth Guide [].
  4. Gilbert RE, Tookey PA. Perinatal mortality and morbidity among babies delivered in water: surveillance study and postal survey. BMJ 1999;319:483–7.
  5. Royal College of Obstetricians and Gynaecologists. Birth in Water. RCOG Statement. London: RCOG; 2001.
  6. Royal College of Midwives. The Use of Water in Labour and Birth. Position Paper no. 1a. London: RCM; 2000 [].
  7. Cluett ER, Nikodem VC, McCandlish RE, Burns EE. Immersion in water in pregnancy, labour and birth. Cochrane Database Syst Rev. 2004;(2):CD000111.
  8. Eriksson M, Mattson L, Ladfors L. Early or late bath during the first stage of labour: a randomised study of 200 women. Midwifery 1997;13:146–8.

Royal College of Obstetricians and Gynaecologists and Royal College of Midwives Joint Statement No.1 4 of 5

  1. Brown L. The tide has turned: audit of water birth. Br J Midwifery 1998;6:236–43.
  2. Cluett ER, Pickering RM, Getliffe K, St George Saunders NJ. Randomised controlled trial of labouring in water compared with standard management of dystocia in first stage of labour. BMJ 2004;328:314.
  3. Department of Health. The National Service Framework for Children and Young People. Maternity Services. Standard 11. (NSF) 2004. London: Department of Health [].
  4. Scottish Executive. A Framework for Maternity Services in Scotland. Edinburgh: Scottish Executive; 2001 [].
  5. Welsh Assembly Children’s Health and Social Care Directorate. National Service Framework for Children, Young People and Maternity Services in Wales. Cardiff: Welsh Assembly Government; 2005 [].
  6. Woodward J, Kelly SM. A pilot study for a randomised controlled trial of water birth versus land birth. BJOG 2004;111:537–45.
  7. Geissbuehler V, Stein S, Eberhard J. Waterbirths compared with landbirths – an observational study of nine years. J Perinat Med 2004;32:308–14.
  8. Anderson T. Umbilical cords and underwater birth. Practising Midwife 2000; 3(2):12.
  9. Anderson T. Time to throw the waterbirth thermometers away. MIDIRS 2004;14(3):370–4.
  10. Geissbuehler V, Eberhard J, Lebrecht A. Waterbirth: water temperature and bathing time –mother knows best! J Paediatr Med 2002; 30:371–8.
  11. National Institute for Clinical Evidence. The Use of Electronic Fetal Monitoring: the useand interpretation of cardiotocography in intrapartum fetal surveillance. London: NICE; 2001 [].
  12. Grunebaum A, Chervenak FA. The baby or the bathwater: which one should be discarded? J Perinat Med 2004;32:306–7.
  13. Nursing and Midwifery Council. Midwives Rules and Standards. London: NMC; 2004 [].
  14. Nursing and Midwifery Council. The NMC Code of Professional Conduct: standards for conduct, performance and ethics. London: NMC: 2004 [www.nmc-]

A comparison of water births and conventional vaginal deliveries

Otigbah CM; Dhanjal MK; Harmsworth G; and others, (July 2000).

European Journal of Obstetrics and Gynecology and Reproductive Biology , vol 91, no 1, July 2000, pp 15-20.

Setting, participants, design and aim:

The study took place in a district general hospital over a five year period, 1989-1994 and involved a total of 602 mothers. A retrospective case-control study which analysed data on 301 mothers who had a water birth and another 301 who had a normal land birth.

The aim was to explore the effects of water immersion on labour and birth, as compared with normal land birth.

Method: The study centre had several pool selection criteria which accepted women who were considered to be at low risk of complication for the pool.

They were required to have: * no medical or obstetric problem; * a gestation of at least 38 weeks with a normal sized fetus; * cephalic presentation; * clear liqour if membranes were already ruptured; * a reactive admission cardiotocograph.

The controls were selected from the unit’s audit data, as the next parity matched woman who was low risk, had a normal birth and did not have labour augmentation.

The variables compared and analysed included: * labour length; * analgesia uptake; * Apgar scores; * maternal complications – namely perineal trauma, postpartum haemorrhage and infection; * neonatal complications – namely shoulder dystocia, admission to special care baby unit (SCBU) and infection.

Data were analysed using the Chi-squared test to compare proportions, and Student’s t test to compare means. Any difference was considered significant if the P value was <0.05. Results: * Primigravidae who had a water birth had a significantly shorter first stage (P <0.05) and second stage (P <0.005) of labour.

The total labour length was 90 minutes shorter; * Water birth mothers, whatever their parity, used significantly less opioid pain relief, either alone or in addition to entonox – 1.3% compared to 54% of the controls (P <0.0001).

A total of 38% water birth women had no analgesia compared to 8% of the control group (P <0.0001); * Water birth mothers had significantly fewer episiotomies – 5%compared to 25% (P <0.0001), although they had more vaginal, 1° and 2° perineal tears overall – 53% versus 39% (P <0.001).

Water birth primigravidae had more intact perinea – 41% compared to 36%, although this was not statistically significant; * Fewer postpartum haemorrhages occurred among water birth mothers – 1.3% versus 2.7%; * One case of maternal pyrexia was reported on a multiparous water birth woman who was treated with antibiotics; she had no positive cultures on subsequent sampling; * No significant difference was reported between the groups in the mean Apgar scores at one and five minutes; *

Two water birth babies were admitted to SCBU with low Apgars.

In one case there was a true knot in the umbilical cord and the other followed a difficult delivery with an unexpected compound presentation; * Five babies in the water birth group and four in the control group had shoulder dystocia; * No neonatal infections were reported.

Abstract writer’s comments:

This is clearly an interesting and worthwhile study which includes data on a good size sample of mothers and babies.

A key strength is the analysis and presentation of the data by parity as often findings relating to primigravidae and multigravidae are amalgamated, despite the influence of parity on factors such as use of analgesia, labour length and type of delivery.

The authors acknowledge the limitations of a non-randomised water group sample.

It would have been interesting to have collected information relating to the social class of pool users, as there is an assumption among health professionals that birthing pools attract greater interest among middle class women, but I know of no evidence to support this view.

The researchers report a shorter labour for water birth primigravidae but do not mention the frequency of vaginal examinations, or whether the second stage was timed when the presenting part was visible, making the precise process of how they timed these labour stages unclear.

The effect of water immersion on analgesia uptake appears striking.

The authors suggest that an influencing factor may have been the continuous midwifery care, often by a known midwife, for pool users, as opposed to an intermittent midwifery presence by a midwife unknown to a mother before her labour.

There is, however, no mention whether any facilities such as beanbags, birthing balls, rocking chairs or floor mattresses were available to women who did not use the pool, apart from presumably a delivery bed.

It is therefore not known whether these women were encouraged to adopt comfortable positions and be as mobile as possible throughout labour.

The practice of maximising maternal mobility has been shown to reduce the perception of pain and thus the uptake of analgesia.

Whilst it is reassuring that fewer episiotomies were performed on water birth women, nonetheless, fifteen still had one!

It would be interesting to know something about the study centre’s approach to care during the second stage regarding pushing techniques and time perimeters, as this could have influenced the incidence of both tears and episiotomies.

The researchers note that ‘particular care was taken to ensure controlled delivery of the head’ (p16) but do not explain how, ie if the midwife touched the head and perineum or not.

Besides, tears often occur with the birth of the shoulders.

Comparison was made between the groups on the incidence of postpartum haemorrhage, but no mother appeared to have a completely physiological third stage because the cord was clamped and cut promptly after the birth, which disturbs the physiology, and the placentas were delivered out of the pool.

The rationale for leaving the pool was to estimate blood loss more accurately – a difficult thing to achieve in or out of water.

A second reason was the totally unproven risk of water embolism.

This study reported no adverse effect for mothers or babies associated with water immersion during labour and birth and forms a useful basis for future research.

Water birth: a review of 848 deliveries and a comparison with other delivery positions

Thoeni A; Holzner J, (2002). International Confederation of Midwives. Midwives and women working together for the family of the world: ICM proceedings CD-ROM Vienna 2002. The Hague: ICM , 2002. 7 pages.


The object of our study was to analyze 848 consecutive water births and to compare them with two other delivery positions.


We compared 848 water births, 493 deliveries in the traditional bed, and 172 deliveries on the delivery stool.

Duration of labor, rates of episiotomies and lacerations, arterial cord blood pH, base excess, analgesic requirements, and postpartum maternal haemoglobin levels were evaluated.


The first stage of labor was significantly reduced in primiparas with water birth compared with the other delivery positions (386 vs. 477 min., respectively).

There were no differences in the duration of the second stage (32 vs 39 min.).

The low episiotomy rate with the water births (1% compared with 18% and 8% for the other two positions) was not associated with an increased rate of perineal lacerations (23% in all three groups).

Of the primipara, 59% had no lacerations with water birth compared with 36% and 46% for the other two positions, respectively.

No woman with water birth required analgesics.

There were no differences among the groups in arterial cord blood pH or postpartal maternal haemoglobin level.


Our results suggest that water birth is associated with a significantly shorter first stage of labor, lower episiotomy rate and perineal lacerations, and reduced analgesic requirements compared with other delivery positions.

Water birth is safe for the mother and fetus-neonate if candidates are selected appropriately.

Study confirms… Women who labour in water have lower rate of epidural analgesia

Randomised controlled trial of labouring in water compared with standard of augmentation for management of dystocia in first stage of labour


To evaluate the impact of labouring in water during first stage of labour on rates of epidural analgesia and operative delivery in nulliparous women with dystocia.

Design Randomised controlled trial.

Setting University teaching hospital in southern England.

Participants 99 nulliparous women with dystocia in active labour at low risk of complications.

Interventions Immersion in water or standard augmentation for dystocia (amniotomy and intravenous oxytocin).

Main outcome measures:

Primary: epidural analgesia and operative delivery rates.

Secondary: augmentation rates with amniotomy and oxytocin, length of labour, maternal and neonatal morbidity including infections, maternal pain score, and maternal satisfaction with care.


Women randomised to immersion in water had a lower rate of epidural analgesia than women allocated to augmentation (47% v 66%, relative risk 0.71 (95% confidence interval 0.49 to 1.01), number needed to treat for benefit (NNT) 5).

They showed no difference in rates of operative delivery (49% v 50%, 0.98 (0.65 to 1.47), NNT 98), but significantly fewer received augmentation (71% v 96%, 0.74 (0.59 to 0.88), NNT 4) or any form of obstetric intervention (amniotomy, oxytocin, epidural, or operative delivery) (80% v 98%, 0.81 (0.67 to 0.92), NNT 5).


Labouring in water under midwifery care may be an option for slow progress in labour, reducing the need for obstetric intervention, and offering an alternative pain management strategy.

(Extract from abstract of Randomised controlled trial of labouring in water compared with standard of augmentation for management of dystocia in first stage of labour by Elizabeth R Cluett, Ruth M Pickering, Kathryn Getliffe, Nigel James, St George Saunders published in British Journal of Midwfery January 26, 2004)

Evidence on the safety of water birth

9 February 2015

Evidence Based Birth – Rebecca Dekker

In April 2014,  waterbirth—an alternative method for pain relief in which a mother gives birth in a tub of warm water—made national headlines.

The event that pushed water birth safetyinto the spotlight was a joint Opinion Statement from the American Congress of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics (AAP), denouncing the practice.

In their opinion statement, ACOG and the AAP firmly admonished that waterbirth should be considered an experimental practice that should only occur in the context of a clinical research study.

Their conclusion, which echoed a previous AAP Opinion Statement from 2005, was based on their opinion that water birth does not have any benefits and may pose dangers for the newborn.

In response, the American College of Nurse Midwives (ACNM),(Midwives 2014) the American Association of Birth Centers (AABC), and the Royal College of Midwives (RCM) all released statements endorsing waterbirth as a safe, evidence-based option.

Meanwhile, the AABC released preliminary data from nearly 4,000 waterbirths that occurred in birth centers all over the U.S., supporting water birth as safe for mothers and infants.

Despite the response from midwifery organizations and the AABC, hospitals all over the U.S. began suspending or shutting down their waterbirth programs.

At St. Elizabeth’s Regional Medical Center in Lincoln, Nebraska, mothers and families organized rallies and started a petition to bring waterbirth back.

All of this controversy left us with these questions— Is the ACOG/AAP statement based on a complete and accurate review of the literature?

What is the evidence on waterbirth?

Is it safe?

Does it have any potential benefits or harms for mothers and infants?

These are the questions we will address in the Evidence Based Birth article on the evidence on waterbirth.

This article was published July 10, 2014, by Rebecca Dekker, PhD, RN, APRN
© Evidence Based Birth, All Rights Reserved.

Click here for a copy of Rebecca Dekker’s paper on the safety of water birth

The use of water immersion in the facilitation of ‘normal labour’


In light of current societal and professional concerns regarding the medicalisation of childbirth and an apparent clinical culture of anxiety and fear of litigation, emerging evidence emphasises the importance of promoting normality within clinical practice, and the need for individualised, client-centred choice and control. 

This article examines the use of water immersion as a facilitator of normal labour and birth. In defining the concept of normality, the article discusses the advantages of water immersion in decreasing maternal pain and use of other analgesics, critically increasing maternal control and satisfaction, and limiting medicalised intervention need. 

Furthermore, supporting the physiological advantages of relaxation and maternal movement linked to the use of water in labour,water immersion promotes improved fetal position and enhanced labour progress. 

Importantly however, the article further identifies current hindering factors to facilitating water immersion implementation, critically the current lack of sound methodological evidence and research rigor regarding potential adverse neonatal outcomes.

It concludes, despite obvious promotion of normality in childbirth, that further robust qualitative and quantitative research is needed to clarify the overall appropriateness of this practice. This would help practitioners to decide if this method is safe and be more informed of the risks and benefits before recommending it to women.


The drive towards promoting normality in labour is evident in current research and policy drivers (RCM 2013; Downe 2008). However, when reading the literature around normal birth, it is apparent that no single set of criteriarepresents an accepted definition of ‘normal labour’ (National Institute of Clinical Excellence [NICE] 2007; Royal College of Midwives [RCM] 2013). 

This debate around what constitutes normality in labour has dominated research and care provision for decades, but, for the purpose of this review, the Midwifery Care Working Party (MCWP) definition will be utilised as the referent. 

This definition states that ‘normal labour’ is spontaneous in onset and progression, without the use of spinal, epidural or general anaesthesia, or medicalised intervention (MCWP 2007).Of particular interest in the support of normality in labour is the issue of medicalised intervention.

For instance, environmental pressures, such as how care is co-ordinated and led,can hinder the process (Russell 2011) and has inadvertently shifted the focus away from normality. Empowering women to take the lead in their own birthing experience, gain personal control and as a result manage their pain more effectively, underpins the definition of normality, whilst also overcoming and eliminating the need for medicalisation (Royal College of Obstetricians and Gynaecologists/Royal College of Midwives (RCOG/RCM 2006). 

Adequate pain relief, such as epidural and pethidine (Nystedt, Edvardsson & Willman 2004; Cho, Lee & Ernst 2010), may induce a more positive birthing experience and personal control; however such methods do not promote normality. For this reason, practices such as water immersion as a non-medicalised method of personal control, may advantageously promote such concepts. 

This review aims to present an overview of current literature around the benefits and disadvantages of using such a method to manage labour pain with an emphasis on critiquing methodological strengths and weakness.

Water immersion and pain relief

Much of the research into pain relief facilitation in childbirth concentrates on comparing the outcomes of water immersion with no intervention during the first stage of labour, in the form of unblinded randomised controlled trials (RCT) (Benfield et al. 2001; Cluett, Pickering, Getliffe & Saunders 2004; Eckert, Turnbull & MacLennan 2001; Ohlsson et al. 2001). 

Despite the limitation of unblinded methodology in these studies, due to the nature of the intervention, collectively they conclude that water immersion has beneficial pain relief implications in comparison with no intervention, and a positive impact on maternal control and normality.

Barbosa da Silva, Vasconcellos de Oliveira and Nobre (2009), in comparing pain relief magnitude in first stage bathing and non-bathing women, conclude that pain is less apparent, and pain progresses lower in bathing cohorts, but overall pain relief satisfaction is highly significant (Pagano et al. 2010; RCOG/RCM 2006). 

However, as this study only involved nulliparous women (first time pregnant)these findings only offer limited insights intothe women’s evaluation of labour pain. The study acknowledges the implications of using such a restricted sample group in representing the entire birthing population.

Regardless of these limitations, the reported reduction in intensity of pain and use of additional analgesia, as concluded within the study’s findings, is indicative of the potential for water immersion to contribute to the promotion of normality in labour by reducing medicalisation. 

This has been replicated by other studies where a decrease in opioid use (Mollamahmutoglu et al. 2012; Cluett, Nikodem, McCandlish & Burns 2009) and incidence of epidural and spinal anaesthetics (Cluett & Burns 2009; Burns et al. 2012) has been concluded. 

Women’s perception of water immersion efficacymay differ prior to commencement of this activity, therefore, this could influence their perception of pain relief (Cluett, Nikodem, McCandlish & Burns 2009); further research is needed to explore this hypothesis.

One qualitative study by Maude and Foureur (2007), which involved interviews with five women who experienced water birth at different post-natal periods, suggests that the anticipation of getting into water and consequential relaxation accelerates the rate of cervical dilation. 

Due to induced cardiovascular changes, any elevation in anxiety hormones is decreased by a reduction in blood pressure, further facilitated by an increased level of endorphins (Benfield 2002; Cluett et al. 2009). Relaxation and a sense of personal control as a response to this, is arguably the main basis for pain relief in water immersion. 

Literature evidence agrees that pain is not eliminated by water; however, relaxation provides a release from the pain experience, and a sense of comfort and satisfaction (McNeil & Jomeen 2010). A larger range of maternal movement improves normal labour progression and there are reported improvements in fetal position and flexion (Cluett et al. 2009; Burns 2004). 

However, the methodology of Maude and Foureur’s (2007) study, in conducting differently timed postpartum interviews, raises questions of recall bias, and potential changing of emotions and opinions over time.

A reduction in medicalised intervention

One point, highly illustrated within the literature, includes the impact of water immersion on the reduced need for medicalised intervention such as episiotomy and induction (Burns et al. 2012; Geissbuehler, Stein & Eberhard 2004). Mollamahmutoglu et al. (2012) report that water immersion results in a shorter second stage of labour,with the need for induction of labour being significantly decreased. 

In connection to facilitating normality through a more natural birthing process, large observational retrospective studies, such as Burns et al. (2012), conclude thata reduced need for medicalised interventions is also more prevalent in midwifery-led home water births. Care within the home is arguably another factor in facilitating normality for the birthing woman. However, a lack of a control group for this particular study, limits the reliability of this study’s conclusions.

Second and third stage management and physiological advantages

Despite water being recommended by national guidance (NICE 2007), there appears to be a small amount of evidence available that concerns labouring in water in the first and second stages. Further water immersion research is needed around these stages of labour, especially in relation to risks associated with delivery of the third stage of labour in water.

However, research undertaken with women who have had a water birth, shows a reduction in maternal adverse outcomes and need for specialised care, compared with vaginal delivery controls. A reduced incidence of perineum tears (Burns et al. 2012), maternal infections (Benfield et al. 2001) and postpartum haemorrhage (Mollamahmutoglu et al. 2012; Benfield 2002), are some of the reported outcomes,all of which promote normality and could, in addition, improve the pain experience.

Definition discrepancies

In analysis of the evidence, various definitions for water immersion can be identified, indicating a lack of homogeneity in research literature. Differences in the size of baths/pools, the depth of water and length of time exposed to the intervention, all contribute significantly to the degree of exposure experienced; however, little attention to date has been paid to these factors. Benfield et al. (2001) conducted a RCT study which exposed its participants to water for exactly an hour.

This, therefore, increased the consistency of their exposure findings; however,the authors state that the pool was shallow in comparison to those generally used on labour wards, thereby limiting the reliability and appropriateness of their findings to practice. Other studies also highlight similar weaknesses. Eckert et al. (2001) used a larger pool during its intervention; however, exposure time varied according to the woman’s preference. 

Significantly, this study also allowed its control group the option of a shower, thereby introducing bias and limiting the reliability of the findings, as exposure to a shower may also have similar pain relief properties as water immersion (Stark & Miller 2009).

Barriers to practice implementation

Interestingly, one factor apparent within the evidence is the lack of investigation into the effects of temperature control, including inconsistencies in temperatures usage and the effect on any potential outcomes. NICE (2007) recommends a water temperature no higher than 37.5c, and advises this should be monitored hourly to ensure maternal comfort and apyrexia (absence of a fever).

Eckert et al. (2001) recognised the importance of temperature control in their RCT study; however,they concludedthat only 50 per cent of the 85 women in the intervention group had their temperatures recorded hourly. In comparison, Benfield et al (2001) assessed water temperature on strict fifteen minute intervals; however, the temperature was allowed to escalate as high as 38c. 

Taking these inconsistencies into account, analysis of the overall literature regarding temperature control and potential pain relief is difficult, and the ability to comment on this specific factor and its relevance in facilitating normal labour remains limited. Evidently, further research is needed in order to eliminate the discrepancies in the methodology, thereby allowing results to be more comparable.

Directly linked to the issue of temperature monitoring is the importance of fetal monitoring. Interestingly, only one study has been found that specifies how fetal heart monitoring was conducted during labour (Mollamatutoglu et al. 2012). On the other hand, a quantitative study conducted by Carpenter and Weston (2012), investigating the differences between respiratory distress in water and land birth neonates, concludes that, despite no significant difference in initial APGAR scores, water immersed neonates have more severe abnormal changes identified through x-ray. 

As this study involved a higher proportion of water birth inspected x-rays in comparison to land birth, this limits the rigor of the methodology, and the exclusion of co-morbidities, such as encephalopathy and congenital heart disease, indicates potential confounding factors. However, the study does conclusively identify the need of further research into potential adverse neonate outcomes after initial APGAR assessment. 

The lack ofstudies into this phenomenon is widely recognised in the literature; the only study to extend assessment over the immediate neonatal period was conducted by Cluett et al. (2004), and thisstudied babies only up to day ten postpartum. Higher incidence of resuscitation (Eckert et al. 2001) and near-drowning (Pinette, Wax & Wilson 2004) further question water immersion as a safe facilitator of normal birth; however, conclusive evidence regarding neonate outcomes is scarce to date; a reliable evidence-based recommendation for practice can only be made once further research has been conducted.

Potentially the largest barrier to water immersion provision so far, does not involve the actual use of water, but the attitudes of the professionals in general and midwives in particular towards its use. Lack of confidence, limited training and pressures from the ward environment seem, on occasions, to override the professional requirement for midwives to facilitate a woman’s choice (Russell 2011).

Working in a medical environment, which super-values intervention over the promotion of a natural birth, has also been identified as an important barrier (Russell 2011).Subsequently, it can be inferred that institutional factors are key in influencingtheuse of water immersion and its potential role in normality facilitation. 

However, the study by Russell (2011) only used a small sample size and findings cannot be readily generalised across the NHS or the entire midwifery profession. Other studies scoping current practice would help understand the use of water in labour in the UK.


As concluded by the current evidence base, research literature largely concurs that water immersion during the first stage of labour is a beneficial, natural method of pain relief. 

This is due to a decreased need for medicalised interventions and additional analgesia, and an increase in personal control and relaxation, consequently facilitating normality in childbirth. 

Lack of evidence on the latter stages of labour, the influence that temperature might have on the labour and/or the baby, and the implications of bathing tub dimensions, require that well conducted, methodologically strong and varied studies of all potential outcomes are carried out.

Despite numerous gaps in the evidence, one significant, largely inconclusive area remains: the lack of research into adverse neonatal outcomes and, specifically, any longer term detrimental effects. Achieving a better understanding of those, could prove advantageous in increasing the uptake of water immersion during labour as facilitator of normality in childbirth.


Barbosa da Silva, F.M., Vasconcellos de Oliveira, S.M.J. & Nobre, M.R.C. 2009. ‘A randomised controlled trial evaluating the effect of immersion bath on labour pain’, Midwifery 25, 286-294.

Benfield, R.D. 2002. ‘Hydrotherapy in labor’, Journal of Nursing Scholarship 34(4), 347-352.

Benfield, R.D., Herman, J., Katz, V.L., Wilson, S.P.& Davis, J.M. 2001. ‘Hydrotherapy in Labor’, Research in Nursing & Health 24, 57-67.

Burns, E.E., 2004. ‘Water: what are we afraid of?’, The Practising Midwife 7(10), 17-19.

Burns, E.E., Boulton, M.G., Cluett, E., Cornelius, V.R. & Smith, L.A. 2012. ‘Characteristics, interventions, and outcomes of women who used a birthing pool: a prospective observational study’, Birth 39(3), 192-202.

Carpenter, L. & Weston, P. 2011. ‘Neonatal consequences from water birth’, Journal of Paediatrics and Child Health 48, 419-423.

Cho, S.H., Lee, H. & Ernst, E. 2010. ‘Acupuncture for pain relief in labour: a systematic review and meta-analysis’, An International Journal of Obstetrics and Gynaecology 117, 907-920.

Cluett, E.R. & Burns, E.E. 2009. ‘Immersion in water in labour and birth’, Cochrane Database of Systematic Reviews 2, 1-56.

Cluett, E.R., Pickering, R.M., Getliffe, K, & Saunders, N.J.S.G. 2004. ‘Randomised controlled trial of labouring in water compared with standard of augmentation for management of dystocia in first stage of labour’, British Medical Journal 328(7435), 1-6.

Cluett, E.R., Nikodem, C.V.C., McCandlish, R.E. & Burns, E.E. 2009. ‘Immersion in water in pregnancy, labour and birth’, Cochrane Database of Systematic Reviews 1, 1-33.

Downe, S. 2008. Normal Childbirth, evidence and debate (2nd edition). Oxford: Churchill Livingstone.

Eckert, K., Turnbull, D. & MacLennan, A. 2001. ‘Immersion in water in the first stage of labour: a randomised controlled trial’, Birth 28(2), 84-93.

Geissbuehler, V., Stein, S. & Eberhard, J. 2004. ‘Waterbirths compared with landbirths: an observational study of nine years’ Journal of perinatal medicine 32(4), 308-314.

Maternity Care Working Party. 2007. ‘Making normal birth a reality-consensus statement from the Maternity Care Working Party-our shared views about the need to recognise, facilitate and audit normal birth’. London: Maternity Care Working Party.

Maude, R.M. & Foureur, M.J. 2006. ‘It’s beyond water: stories of women’s experiences of using water for labour and birth’, Women and Birth 20, 17-24.

McNeil, A. & Jomeen, J. 2010. ‘“Gezellig”: a concept for managing pain during labour and Childbirth’, British Journal of Midwifery 18(8), 515-520.

Mollamahmutoglu, L., Moraloglu, O., Ozyer, S., Su, F.A., Karayalcin, R., Hancerlioglu, N.,Uzunlar, O., & Dilmen, U. 2012. ‘The effects of immersion in water on labor, birth and newborn and comparison with epidural analgesia and conventional vaginal delivery’, Journal of Turkish German Gynecological Association 13, 45-49.

National Institute of Clinical Excellence (NICE). 2007. ‘Intrapartum care-care of healthy women and their babies during childbirth’. London: National Institute of Clinical Excellence.

Nystedt, A., Edvardsson, D., & Willman, A. 2004. ‘Epidural analgesia for pain relief in labour and childbirth- a review with a systematic approach’, Journal of Clinical Nursing 13, 455-466.

Ohlsson, G., Buchhave, P., Leandersson, U., Nordstrom, L., Rydhstrom, H. & Sjolin, I. 2001. ‘Warm tub bathing during labor: maternal and neonatal effects’, Acta Obstetricia et Gynecologica Scandinavica 80(4), 311-314.

Pagano, E., De Rota, B., Ferrando, A., Petrinco, M., Merletti, F., Gregori, D. 2010. ‘An economic evaluation of water birth: the cost-effectiveness of mother well-being’, Journal of Evaluation in Clinical Practice 16, 916-919.

Pinette, M.G., Wax, J. & Wilson, E. 2004. ‘The risks of underwater birth’, American Journal of Obstetrics and Gynecology 190, 1211-1215.

Royal College of Midwives (RCM). 2013. ‘Campaign for Normal Birth’. Available online at:

Royal College of Obstetricians and Gynaecologists/Royal College of Midwives (RCOG/RCM). 2006. ‘Immersion in water during labour and birth’. London: Royal College of

Obstetricians and Gynaecologists and Royal College of Midwives.

Russell, K. 2011. ‘Struggling to get into the pool room? a critical discourse analysis of labor ward midwives’ experiences of water birth’, International Journal of Childbirth 1(1), 52-60.

Stark, M.A. & Miller, M.G. 2009. ‘Barriers to the use of hydrotherapy in labor’, Journal of Obstetric, Gynecologic, & Neonatal Nursing 38, 667-675.

Immersion in water in labour and birth | Cochrane Summaries 2012

Elizabeth Cluett, Ethel Burns

This review includes 12 trials (3243 women).

Water immersion during the first stage of labour significantly reduced epidural/spinal analgesia requirements, without adversely affecting labour duration, operative delivery rates, or neonatal wellbeing.

One trial showed that immersion in water during the second stage of labour increased women’s reported satisfaction with their birth experience.

Further research is needed to assess the effect of immersion in water on neonatal and maternal morbidity.

No trials could be located that assessed the immersion of women in water during the third stage of labour, or evaluating different types of pool/bath.


Enthusiasts suggest that labouring in water and waterbirth increase maternal relaxation, reduce analgesia requirements and promote a midwifery model of care.

Critics cite the risk of neonatal water inhalation and maternal/neonatal infection.


To assess the evidence from randomised controlled trials about immersion in water during labour and waterbirth on maternal, fetal, neonatal and caregiver outcomes.

Search strategy:

We searched the Cochrane Pregnancy and Childbirth Group’s Trials Register (30 June 2011) and reference lists of retrieved studies.

Selection criteria:

Randomised controlled trials comparing immersion in any bath tub/pool with no immersion, or other non-pharmacological forms of pain management during labour and/or birth, in women during labour who were considered to be at low risk of complications, as defined by the researchers.

Health topics:

Pregnancy & childbirth > Care during childbirth > Normal labour & birth Pregnancy & childbirth > Care during childbirth > Routine intrapartum care
Data collection and analysis:

We assessed trial eligibility and quality and extracted data independently. One review author entered data and the other checked for accuracy.

Main results:

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.

Results for the first stage of labour showed there was a significant reduction in the epidural/spinal/paracervical analgesia/anaesthesia rate amongst women allocated to water immersion compared to controls (478/1254 versus 529/1245; risk ratio (RR) 0.90; 95% confidence interval (CI) 0.82 to 0.99, six trials).

There was also a reduction in duration of the first stage of labour (mean difference -32.4 minutes; 95% CI -58.7 to -6.13).

There was no difference in assisted vaginal deliveries (RR 0.86; 95% CI 0.71 to 1.05, seven trials), caesarean sections (RR 1.21; 95% CI 0.87 to 1.68, eight trials), use of oxytocin infusion (RR 0.64; 95%CI 0.32 to 1.28,five trials), perineal trauma or maternal infection.

There were no differences for Apgar score less than seven at five minutes (RR 1.58; 95% CI 0.63 to 3.93, five trials), neonatal unit admissions (RR 1.06; 95% CI 0.71 to 1.57, three trials), or neonatal infection rates (RR 2.00; 95% CI 0.50 to 7.94, five trials).

Of the three trials that compared water immersion during the second stage with no immersion, one trial showed a significantly higher level of satisfaction with the birth experience (RR 0.24; 95% CI 0.07 to 0.80).

A lack of data for some comparisons prevented robust conclusions.

Further research is needed.

Authors’ conclusions:

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 labouring in water or waterbirth.

However, the studies are very variable and considerable heterogeneity was detected for some outcomes.

Further research is needed.

BMC Pregnancy and childbirth – Immersion in water for pain relief – 2014

Immersion in water for pain relief and the risk of intrapartum transfer among low risk nulliparous women: secondary analysis of the Birthplace national prospective cohort study

Mirjam Lukasse, Rachel Rowe, John Townend, Marian Knight and Jennifer Hollowell


Background: Immersion in water during labour is an important non-pharmacological method to manage labour pain, particularly in midwifery-led care settings where pharmacological methods are limited.

This study investigates the association between immersion for pain relief and transfer before birth and other maternal outcomes.


A prospective cohort study of 16,577 low risk nulliparous women planning birth at home, in a freestanding midwifery unit (FMU) or in an alongside midwifery unit (AMU) in England between April 2008 and April 2010.


Immersion in water for pain relief was common; 50% in planned home births, 54% in FMUs and 38% in AMUs.

Immersion in water was associated with a lower risk of transfer before birth for births planned at home (adjusted RR 0.88; 95% CI 0.79–0.99), in FMUs (adjusted RR 0.59; 95% CI 0.50–0.70) and in AMUs (adjusted RR 0.78; 95% CI 0.69–0.88).

For births planned in FMUs, immersion in water was associated with a lower risk of intrapartum caesarean section (RR 0.61; 95% CI 0.44–0.84) and a higher chance of a straightforward vaginal birth (RR 1.09; 95% CI 1.04–1.15).

These beneficial effects were not seen in births planned at home or AMUs.


Immersion of water for pain relief was associated with a significant reduction in risk of transfer before birth for nulliparous women.

Overall, immersion in water was associated with fewer interventions during labour.

The effect varied across birth settings with least effect in planned home births and a larger effect observed for planned FMU births.

Full article is available to read via the link below and is highly recommended, with some very detailed analysis and insight into methods of study with statistical support.

Please click here to read the full publication


Exploring breech water birth

Maggie Banks – RM, PhD, ADN, RGON

The paucity of literature on labour and birth in water with breech- presenting babies highlights a need to share (and document) empirical knowledge on the subject to piece together women’s and midwives’ growing experiences.

I was asked recently if leaving a woman in a birth pool to give birth to a breech presenting baby, undiagnosed until on the perineum, was ‘reasonable’ midwifery practice.

The question was qualified in that if the breech baby had been known prior to labour, the birth would definitely not have occurred in water as it is contraindicated in all the waterbirth guidelines in New Zealand.

My initial reaction, though fleeting, was to shrink away and not own my own experiences, knowing that these would be viewed as ‘unreasonable’ given that guidelines were presented as a self-evident truth that could not be argued with, that is, a known breech baby would not be born in water.

The issue of breech presentation and waterbirth is one that I have repeatedly explored in the midwifery and obstetric literature over the years and have found little written on the subject.

What is there usually cites the same source – Herman Ponette, the Belgium obstetrician in Ostend who actively promotes waterbirth with breech babies.1 There is minimal acknowledgement that it occurs in hospitals in the USA and the UK.2, 3

A Google search using the term ‘breech waterbirth’ brings up a handful of consumer stories and the occasional midwifery website which discusses the issue. Of the numerous stories I receive from women and midwives about breech birth, increasingly they involve the use of water.

This article pieces together some knowledge gained from reading, discussions, several of my experiences of, and reflections on, the use of water immersion with breech babies.

Going with the Flow

Initially I had been mindful of Michel Odent’s recommendation of not using deep warm water during breech labour as he warns that the soothing effect of water may mask an unduly painful labour, thereby preventing early detection of what may prove to be a problematic birth.4

My own first experience of using water in a breech labour happened by accident in that the frank breech baby remained undiagnosed until on the perineum. The woman had used the pool unconventionally in labour – she chose to lounge in the pool between contractions and stood during them. Once the breech was diagnosed I asked her to leave the pool and she stood to give birth.

This made me re-look at Michel’s caution. My experience of waterbirth with cephalic presentation had shown me that water immersion only mellows out normal labour pain, not severe or pathological pain, which would indicate the bone on bone painof true disproportion between pelvis and presenting part.

I had to question why this should be any different for a breech presenting baby – and I could not find an answer.

With the same woman’s second frank breech baby, this time diagnosed in pregnancy, she again used the pool unconventionally to relax between her contractions, and she birthed standing on dry land.

These two experiences marked a small shift in the use of water during my attendance at breech labour and birth in that water immersion remained available with a known breech. However, I continued to arrange with women that they would leave the pool for birthing.

This request changed following the birth of Heath, a firstborn presenting as a flexed legs breech. His mother had been deeply relaxed in the pool, assuming a wide open kneeling position leaning over the edge of the pool.

When the baby was visible on the perineum and the urge to push was overwhelming I asked the woman to leave the pool as we had prearranged, which she did.

Whereas she had been strong, independently held her own weight, and was powerful in her pushing, once out of the pool, she needed physical support to be in active birth positions and was unable to relax deeply between contractions as she had previously done in the pool.

The baby was born within half an hour of pushing and all was well but it was clear to me that I had intervened in a physiological birth and this had altered the ease with which the woman gave birth.

This birth occurred some months after the 1st International Waterbirth Conference in 1995.

Publication of Paul Johnson’s classic article 5 on the mechanisms that prevent or, conversely, stimulate breathing in the unborn baby during waterbirth would occur the following year but, in concluding his conference write up, Johnson, a Consultant Clinical Physiologist in the O&G Department at the John Radcliffe Hospital in Oxford, wrote:

“…if the onset of labour is spontaneous, and no drugs are administered, a fetus born with its cord intact, into warm, fresh water, not asphyxiated, is inhibited from breathing”6 – a process not dependant on presentation.

Initiation of breathing following waterbirth occurs once the baby surfaces and is exposed to cooler, dryer air and clamping the umbilical cord 6 – again, irrespective of presentation.

Sheila Kitzinger would report his additional comment that “if water births are of psychological and physiological benefit, it is logical that this benefit should apply to high-risk women too”.7

I knew deep water immersion to be a very powerful modality for achieving a relaxed state for the woman, enhancing vasodilation and placental perfusion and, therefore, oxygenation, of the tissues and organs, including the placenta during the normally stressing (not distressing) time of labour.

I had seen women become oblivious to everyone and everything as they sank into the pool. I had come to recognise the depth of sigh on entering the pool that signalled release of pain, fear, social etiquette and conversation – and these observations were irrespective of whether the baby was coming head or bottom first.

The Buoyancy and Warmth of Water

Another dimension was added when I attended a woman with twins, the second baby being a breech presentation. The woman had grown her babies well and began labour spontaneously at 40 weeks.

Due to the heaviness of her abdomen, she was drawn to labouring in water – her bath at home then, when labour was well established and she had travelled to her chosen birth place, the spa bath in the obstetric hospital.

There was a point in her labour where she needed to be more upright than reclining in the spa bath allowed, so we set up my free standing birth pool for her.

With the water up to the level of her breasts she became almost weightless in the pool, and was able to assume her intuitive positioning in a deep squat for the births of both her babies, the second of which had remained breech.

The woman reflected how supportive the water had been and how the upright position engaged her strength and ability to birth well.

Controlling Pelvic Pressure

When vaginal breech birth was a common occurrence 15 years or so ago, epidural anaesthesia was commonly recommended to overcome a premature urge to push. However, discussion with midwifery colleagues indicates a premature urge to push with a term breech baby is rare in woman-controlled positioning.

One woman who did experience significant pelvic pressure from the onset of labour with spontaneous rupture of membranes while having her first baby – a frank breech presentation – provided a piece to the mosaic of the use of water.

She controlled the urge to push by long and slow breathes during contractions and lying on her side on a floor mattress for most of her labour, rising only to crawl to the toilet on her hands and knees. After 12 hours of this, the pressure was overwhelming, even when lying.

While her good progress was evident from the lengthening burgundy buttock crease and her birthing energy, it was not time to use that expulsive energy. A vaginal examination confirmed a thin rim of cervix remained.

While a hands and knees position reduced the pressure, it was not until she lounged in the pool on her abdomen that the pressure again became tolerable. The pool was invaluable for enabling her to resume breathing over the contractions for the next three hours.

In the last hour prior to the birth, the woman commenced her grunting expulsions. As this had not brought her baby to a visible position in that time, I asked her to stand for one contraction to test the power of this feeling.

Simply standing engaged the pelvic pressure enough to bring the baby to almost rumping with the first push.

The second surge saw the baby rumped and progress so the popliteal spaces (back of the knees) were visible. With the next, he was born to the ankles, then descended quickly to wear his ‘perineal hat’ and his head was gently released without perineal trauma. All of this occurred without a contraction as the women responded to the pelvic pressure.

Assessing the Baby

The New Zealand Guideline Group’s best practice evidence-based guideline on breech labour and birth acknowledges that the evidence does not support continuous electronic foetal heart rate (EFM) monitoring by cardiotocography over intermittent auscultation.8

This is because, just as for well women and their babies with no alerting factors, there are no significant differences in standard measures of newborn wellbeing (including cerebral palsy and infant mortality) with continuous EFM in labour for ‘high risk’ situations, which frank or flexed legs breech presentation at term is deemed to be by some.

Only beneficial for its association with a reduced incidence of neonatal seizures, continuous EFM is associated with increased maternal morbidity by way of the accompanying increase in Caesarean and operative birth rates.9

At any given point the midwife needs to know that the baby is coping well with labour by assessment of his movements10 and listening to his heart beat.

As with any other labour for well women and babies, listening can be easily acheived with a Pinard stethoscope (or handheld, waterproof doppler) during water immersion.

Essential Elements of Physiological Breech Birth

Midwives commonly reflect on how their practice changes with attending waterbirths of cephalic presenting babies to become more ‘hands-off ’ during birth.

Confident that the water frequently dissipates urges to explosively push, while also supporting the woman’s perineal tissues and the baby as he is born, the midwife is drawn to a non touch vigilant attendance. This ‘hands off ’ in the absence of problems is the ‘golden rule’ during breech birth.

Maternal effort is an important part of achieving a ‘hands-off ’, spontaneous birth. As with any birthing, the woman needs to be supported to choose positions of comfort in the water which enhance her power and strength – kneeling, squatting, hands and knees or reclining.

Whichever birth position is chosen, the midwife needs to position herself so she can see both the advancing baby and the umbilical cord, and be in a position to palpate the umbilical cord if necessary.

The midwife may need ‘hands on’ for the birth of the head but the support of the water usually ensures gentle and woman- controlled birth of the baby’s head. Due to the reduction in gravity and an accompanying reduction in an urge to push for the head, the woman may need to be reminded to release the baby’s head.

Midwives who regularly attend waterbirths with cephalic presentation frequently reflect that if there is a problem during birth, for example, shoulder dystocia, they will initially try to correct it in the pool.

This avoids delay while utilising the water’s buoyancy so the woman can move easily to adopt very wide open positions that are needed for manoeuvres.

While Pinotte1 notes a reduced need for routine manipulations of the breech baby with waterbirth, in the rare circumstance that a manoeuvre is needed – to bring down stuck arms11 and/or flex, cradle and scoop out the baby’s head12 – these could also initially be done in the pool, again, avoiding delay.

The woman, however, would be asked to get out of the pool if problems were not easily remedied.

The Ongoing Mosaic

For some maternity professionals the issue of vaginal breech birth is no longer worth considering in the wake of the Term Breech Trial13 despite concerns about its methodological flaws.14-17

For others it remains a planned option.18-22 There will, of course, always be undiagnosed breech babies in labour, irrespective of the degree of antenatal scrutiny.

While some consider undiagnosed breech an ‘obstetric emergency’, the manner in which a midwife facilitates
a vaginal breech birth, first diagnosed when birth is imminent, is the sameas if it was diagnosed antenatally and a vaginal breech birth is planned, albeit the latter having obstetric backup available with the birth in an obstetric hospital.

The use of deep water immersion with mal-presentation (read: breech)
is contraindicated in hospital clinical guidelines on waterbirth, and the use of water is absent as a modality in vaginal breech birth guidelines.

Embracing these, giving birth in water to a breech baby would be out of the question for some maternity providers.

Yet others are very specific
 in seeing breech presentation as a positive indication for waterbirth because of the buoyancy afforded to the baby and umbilical cord, both of which are kept warm in the water until surfacing into the cooler air,1,23,24 contraindicated only if the breech labour is not progressive and/
or is complicated.25

Midwifery can have additional knowledge fragments to obstetric knowledge, gained by our deep relationships with women.

Being attentive to women who are called to use water through breech labour and birth and walking side by side with them during this time has added to my understanding of facilitating physiological breech birth.

We need to be able to share the practice wisdom which comes from our experiences, discussions and reflections. We also need to be able to do this without fear of repercussions that may be activated from that disclosure. As a result, we will continue to find ongoing pieces to the mosaic of breech waterbirth.


Ponette H. Breech and twin deliveries in the water. Accessed 20 March 2000. Available at fi/~lauhakan/whale/waterbaby/p6.html
Kitzinger S. Sheila Kitzinger’s letter from England. Birth 1991;18(3):170–171.
Harper B. Waterbirth basics – from newborn breathing to hospital protocols. Midwifery Today 2000;54:9– 10,12–15,68.
Odent M. Birth reborn. Souvenir Press: New York, 1984:103–105.
Johnson P. Birth under water – to breathe or not to breathe. BJOG: An International Journal of Obstetrics and Gynaecology 1996;103(3):202–208.
Johnson P. Birth under water – to breathe or not to breathe. In, Lawrence Beech BA (ed).Water birth unplugged. Proceedings of the First International Water Birth Conference. Books for Midwives: Cheshire, England, 1996:31–33.
Kitzinger S. Sheila Kitzinger’s letter from England: is water birth dangerous? Birth 1995; 22(3):172–173.
New Zealand Guidelines Group. Care of women with breech presentation or previous Caesarean birth. New Zealand Guidelines Group: Wellington, 2004:xxi, 32.
Alfirevic Z, Devane D, Gyte GML. Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour. Cochrane Database of Systematic Reviews 2006, Issue 3. Art. No.: CD006066. DOI: 10.1002/14651858. CD006066.
Banks M. Utilising the unborn baby’s in-labour movements. New Zealand College of Midwives Journal 2003;29:6.
Banks M. Breech birth woman-wise. Birthspirit: Hamilton, New Zealand, 1998:88–89.
Ibid., pp. 90–91.
Hannah M, Hannah WJ, Hewson SA, Hodnett ED, Saigal S, et al. Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicenter trial. Lancet 2000;356:1375–1383.
Glezerman M. Five years to the term breech trial: the rise and fall of a randomized controlled trial. American Journal of Obstetrics and Gynecology 2006;194(1):20–25.
Kotaska A. In the literature: combating coercion: breech birth, parturient choice, and the evolution of evidence-based maternity care. Birth 2007;34(2):176–180.
Keirse MJNC. Evidence-based childbirth only for breech babies? Birth 2002;29(1):55–59.
Goer H. When research is flawed: planned vaginal birth versus elective Cesarean for breech presentation. Accessed 14 August 2007. Available at Research/WhenResearchisFlawed/ VaginalBreechBirth/tabid/167/ Default.aspx
Goffinet F, Carayol M, Foidart J, Alexander S, Uzan S, et al. Is planned vaginal delivery for breech presentation at term still an option? Results of an observational prospective survey in France and Belgium. American Journal of Obstetrics and Gynecology 2006;194(4):1002–1011.
Hellsten C, Lindqvist PG, Olofsson P. Vaginal breech delivery: is it still an option? European Journal of Obstetrics & Gynecology and Reproductive Biology 2003;111(2):122–128.
Sibony O, Luton D, Oury J, Blot P. Six hundred and ten breech versus 12,405 cephalic deliveries at term: is there any difference in the neonatal outcome? European Journal of Obstetrics & Gynecology and Reproductive Biology 2003;107(2):140–144.
Giuliani A, Schöll WMJ, Basver A, Tamussino KF. Mode of delivery and outcome of 699 term singleton breech deliveries at a single centre. American Journal of Obstetrics and Gynecology 2002;187(6):1694–1698.
van Roosmalen J, Rosendaal F. There is still room for disagreement about vaginal delivery of breech infants at term. BJOG: An International Journal of Obstetrics and Gynaecology 2002;109(9):967–969.
Charkowsky I. In: Napierala S. Water birth: a midwife’s perspective. Bergin & Garvey: London, 1994:181–182.
Enning C. Personal communication, 2008.
Ponette H. The New Aquatic Maternity in Ostend. Accessed 20 March 2000. Available at fi/~lauhakan/whale/waterbaby/p2.html

New Zealand College of Midwives – Use of water for labour & birth

The New Zealand College of Midwives (Inc) supports immersion of women in warm water during labour as a method of pain management.

There is no evidence that remaining in water for the birth of the baby leads to adverse outcomes for the mother or baby where the labour has been within normal parameters.
Definition:Water birth means where a baby is born fully submerged into water.Rationale:

  • Evidence supports immersion in warm water as an effective form of pain relief that reduces the use of narcotics.
  • There is no evidence to suggest that immersion in water during labour or birth in water leads to any detrimental effects for either the mother or her baby.
  • Evidence that immersion in water during labour reduces the length of active labour is inconclusive.
  • Evidence that birth in water reduces perineal trauma or blood loss is inconclusive.


Midwives offering water immersion for labour and for birth are responsible for ensuring the information given to women is accurate and up to date. The following guidelines are recommended:

  • There are no adverse factors noted in foetal or maternal wellbeing during labour.
  • Baseline assessments of both maternal and baby wellbeing should be done prior to entering the bath/pool and assessments continued throughout the time in water as for any normal labour.
  • Vaginal examinations can be performed with the woman in water.
  • Pethidine should not be given to women labouring in water.
  • The water temperature should be kept as cool as the woman finds comfortable during the first stage of labour (around 35oC) and increased to no more than 37oC for the baby’s birth.
  • If maternal temperature rises more than 1oC above the baseline temperature then the water should be cooled or the woman encouraged to leave the bath/pool. Women need to be aware of this in advance.
  • Water temperature should be recorded as the woman enters the bath/pool and regularly during the time she remains in the pool.
  • Careful documentation should be kept of maternal and water temperatures, FHR and the approximate surface area of the woman’s body submerged.
  • The cord should not be clamped and cut until after the birth of the baby’s body.
  • The baby should be brought to the surface immediately, with the head facing down to assist the drainage of water from the baby’s mouth and nose.
  • The baby’s body can remain in the water to maintain warmth, unless the baby’s condition dictates otherwise. (Note: babies born in water may take slightly longer to establish respirations than those born into air. Maintain close observation of colour, heart rate and respirations.)
  • Third stage should be managed physiologically as for any other low risk birth. If oxytocin is required or third stage is prolonged the woman is assisted to leave the bath/pool.
  • Midwives must ensure that baths and pipes are thoroughly cleaned after use.


Title: Labour and delivery in the birthing pool
Author: Forde, C, Creighton, S, Batty, A, Howden, J, Summers-Ma, S, and Ridgeway, G

Title: Warm tub bathing during labour: maternal and neonatal effects
Authors: Ohlsson, G, Buchave, P, Leandersson, U, Nordstrom, L, Rydhstrom, H, and Sjolin, I
Source: Acta Obstetricia et Gynecologica Scandinavica, Vol 80, pp 311 – 314, 2001

Title: Immersion in water in the first stage of labour: a randomised controlled trial Authors: Eckert, K, Turnbull, D, and MacLennan, A
Source: Birth, Volume 28, No 2, pp 84–93, June 2001

Title: Immersion in water during first stage of labour
Author: Homer, C
Source: Letter to the editor, Birth, Vol. 29, No 1, March, 2002

Title: Waterbirths: a comparative study. A prospective study on more than 2000 waterbirths
Authors: Geissbuhler, V and Eberhard, J
Source: Foetal Diagnosis Therapy, Vol. 15, pp. 291 – 300, 2000

Title: Immersion in water in pregnancy, labour and birth
Author: Nikodem, VC
Source: Cochrane Database Systematic Review, 2000

Title: Perinatal mortality and morbidity among babies delivered in water: surveillance study and postal survey
Authors: Gilbert, R and Tookey, P
Source: British Medical Journal, 319 (7208), pp. 483 – 487, 1999

Title: Birth under water – to breathe or not to breath
Author: Johnson, P
Source: British Journal of Obstetrics and Gynaecology, 103, 202-208, 1996

Title: Labour and birth in water: temperature of pool is important
Authors: Deans, AC and Steer, PJ
Source: British Medical Journal. 311:390-391, 1995

Title: Waterbirth – An attitude to care
Author: Garland, D
Source: Books for Midwives, 1995. Chesire

Title: Foetal hypothermia risk from warm water immersion
Author: Charles, C
Source: British Journal of Midwifery

Water birth and newborn GBS disease

Judy Slome Cohain

originally published December 2010

Abstract: A single case of early onset newborn Group B Strep was documented among 4,432 hospital births into water in the absence of GBS prophylaxis, suggesting that low risk women giving birth into water have a 300% lower rate of newborn GBS disease newborns than dry, full term births delivered by current GBS guidelines.

Possible explanations include:

1) Inoculating the baby with mother’s intestinal flora at birth protects against GBS infection;

2) Bath water washes off the GBS bacteria acquired during the descent through the vagina;

3) Pool dilutes the GBS among a multitude of other intestinal bacteria which compete with GBS;

4) Early onset GBS disease is prevented by lower level of interventions at water birth which promotes maternal and fetal immune function;

5) Kangaroo care after water birth promotes immune function of mother newborn dyad. Much is still to be learned from research documenting birth into water.

Group B Strep (GBS) inhabits the intestines.

Some minutes before the time of birth, the descending fetal head usually causes fecal matter to be excreted. If the woman is in water, the feces enters the water.

A bathtub can be quickly emptied before the fetal head is born.

If she is in a pool, the warm water is likely to be inoculated with GBS. Warm wet conditions enhance the reproduction of bacteria, increasing their numbers exponentially every few minutes.

If the baby’s is born into the warm, feces-exposed water, the baby is exposed to the mother’s intestinal bacteria.

Exposing the baby to the mother’s own natural flora is known to be one of many protective processes that are meant to take place immediately after birth.

Even so, birthing a baby into a feces soiled pool may be considered by many to be likely to increase the risk of newborn infection.

However, evidence of adverse outcomes is lacking.

A report of 4,030 births into water reports no deaths from early onset GBS and one GBS infection.

(1) Information is lacking as to whether the reported GBS-infected baby may also have had a chromosomal abnormality and/or increased blood loss from a snapped umbilical cord or shoulder dystocia.

When this study was conducted, the full term dry birth rate for GBS disease was six times higher (1 in 588) than the waterbirth GBS rate.

The current full term dry birth GBS rate is three times higher (1 in 1,450) than the reported waterbirth rate.(3)

The Cochrane review (2) includes three additional studies tallying another 402 women who birthed their babies into water for which no cases of newborn GBS infection occurred.

The full term waterbirth GBS rate is therefore, a fraction of the dry birth GBS infection rate even after implementation of the US Center for Disease Control (CDC) protocols.

The rate of early onset GBS disease among newborns born before 37 weeks gestation was 1 in 330(3).

Unfortunately research is lacking for whether this rate could also be lowered by birthing into water.

The 2010 CDC Guidelines (5) begins with the statement : “Maternal intrapartum GBS colonization is the primary risk factor for early-onset disease in infants.”

This statement is derived solely from data from interventive land birth, therefore making an incorrect assumption that all births take place in interventive hospital environments.

The evidence regarding GBS and waterbirth is missing from the CDC Guidelines. Objecting to the hospital waterbirth data on the basis of it not being randomized or a small sample is negated by the fact that there are no RCT trials supporting CDC Guidelines(4) and the largest samples included in the new CDC protocols are nonrandomized samples of 5,000 and 7,600 used to
support the low rate of anaphylaxis in women given prophylactic antibiotics. ( 5 )
The CDC(5) states definitively that “GBS also can invade through intact membranes (32,33)”.

The words ‘invade through intact membranes’ explicitly describes GBS making a hole rather than a blood borne mechanism.

This statement contradicts a later statement in the same protocols that early newborn GBS infection following elective CS in the presence of intact membranes is either completely or almost non-existant.

The only references supporting GBS ‘invading thru intact membranes’ are from 1984(6) and 1988(7) and do not refer to full term birth.

The first reports on 15 births less than 1000 g, before 28 weeks and all suffering from symptomatic intrauterine infections before birth.

The second reference states: “10-50% of group B streptococcal infections occur in the presence of intact membranes” which is a wild supposition not supported by any other research.

A mechanism is lacking for how GBS might have crossed both the amnion’s and chorion’s thick cross-linkages in the collagen triple helix that provide strength to the collagen.

The compact fibroblast layers of connective tissue beneath the basement membrane form a fibrous barrier. Interstitial collagens predominate and form parallel bundles of collagen fibrils that maintain the mechanical integrity of the amnion.

As an experienced practitioner knows, even with the aid of a sharp amniohook, it can be challenging to break thru two layers of healthy membranes without the presence of a bulging bag of water.

A close examination of CDC guidelines brings into question why certain dubious research is included and other research missing.

While birthing into water may appear counterintuitive, evidence strongly suggests that it protects babies from GBS disease.

Five possible mechanisms for how water birth may protect against GBS disease are suggested in the abstract.

While infusing women with high doses of IV antibiotics to suppress the GBS before the baby passes through, has been widely accepted as current protocol, the Cochrane review emphasizes the lack of RCT studies and the high risk of bias in the 3 small studies that exist. (4)

Routine antibiotic prophylaxis makes light of the biological adaptive abilities of bacteria.

Bacteria have developed many intriguing mechanisms like selectively pumping antibiotics out of their bodies and even digesting antibiotics for nutrition.(8)

The microorganism producing the antibiotic, must have a mechanism to keep itself unharmed by the antibiotic it produces.

Therefore, perfect antibiotic ‘resistance’, a euphemism for immunity, exists before the antibiotic is created.

GBS disease is increasing.

The overall incidence of early onset GBS disease of the newborn showed an initial downward trend from 2000 to 2003 (0.52 to 0.31 cases per 1,000 live births) followed by an increase from 2003 to 2006 (0.31 to 0.40 cases per 1,000 live birth.(9)

Not only is early onset GBS increasing but late onset GBS which is immune to prophylaxis is also increasing above previous levels (2003–2005).(9)

Finally, adult GBS has increased by 32% and it is predicted that this rate will continue to increase.(9)

Seven percent of adults are allergic to penicillin and therefore already have no effective treatment for the 20% of GBS that is erythromycin- and clindamycin- resistant(4).

In addition, a new disease that causes painful vaginal burning sensation without relief for years, called long-term symptomatic GBS vaginitis, first described in case studies in 1997, is now becoming more and more common and likely involves antibiotic resistant strains of GBS, since antibiotics are not consistently useful to eradicate it.(10)

Hospital Birth into Water data appears to provide the lowest Newborn GBS disease outcomes available without increasing the dangers of antibiotic resistance.


1. Gilbert R.E. and P.A. Tookey. 1999. Perinatal mortality and morbidity among babies delivered in water: surveillance study and postal survey. BMJ 319: 483–87.

2. Cluett, E.R. and E. Burns. 2009. Immersion in water in labour and birth. Cochrane Database of Systematic Reviews (2) DOI: 10.1002/14651858.CD000111.pub3.

3. Phares C.R., et al. 2009. Epidemiology of invasive group B streptococcal disease in the United States, 1999-2005. JAMA 299(17): 2056–65.

4. Ohlsson A, Shah VS. Intrapartum antibiotics for known maternal Group B streptococcal colonization. Cochrane Databaseof Systematic Reviews 2009, Issue 3. Art. No.: CD007467.

5. Prevention of Perinatal Group B Streptococcal Disease. Revised Guidelines from CDC. 2010. November 19, 2010/59(RR10);1-32.

6. Desa DJ, Trevenen CL. Intrauterine infections with group B beta-haemolytic streptococci. Br J Obstet Gynaecol 1984;91:237–9.

7. Katz V, Bowes WA Jr. Perinatal group B streptococcal infections across intact amniotic membranes. J Reprod Med 1988;33:445–9.

8. 9132AF8A95CA0642 Accessed 1 Sept 2010.

9. Centers for Disease Control and Prevention. 2009. Trends in perinatal group B streptococcal disease — United States, 2000–2006. MMWR Morb Mortal Wkly Rep 58(5): 109–12.

10. Cohain, J.S. 2009. Long term Symptomatic GBS Vulvovaginitis — eight cases resolved with freshly cut garlic. Eur J Obstet Gynecol Reprod Biol 146(1): 110–11.

Aspects of the humanisation of water birth

23 October 2015: Yesie Aprillia S.Si.T, M.Ke

Originally published 31 January 2011

In the development of modern obstetrics the most important thing to be performed is the humanization of the labor and birth process.

This is an approach focused on the family, patient autonomy and pain management. This effort is essential for fetal and neonate safety.

The Royal College of Gynecologist and Obstetricians published guidelines, protocols were agreed upon, to prevent complications that are not predictable.2, 3

Thus guidelines are absolutely needed by the service provider of water birth. Guidelines or protocols are a main reference when formulating a basic approach to the patient and her family.

Some of the existing research indicates that being in the water during labor and childbirth provides a significant advantage in birth outcomes.

Each maternity unit should have a policy of water birth, including guidelines for patient preparation including information about water birth.

Service providers should be required to provide guidance on the process of childbirth to mother and family.2, 3,4,5,6

Understanding the risk factors that will be experienced by the mother and the baby is important, so that the prospective mother is completely ready to do the water birth.

Labor protocol is a matter that absolutely must be upheld to prevent risks and complications during labor.6

Considering risk for the baby is important.

However, the majority of medical experts believe that this situation is very rare, because babies will not breathe until the baby is exposed to air.7, 8

In 1999, Gilbert, et al published their research in 1996 by taking a sample of 4032 infants born in the water.

This study concluded that the prenatal mortality is not significantly higher than the risk of conventional childbirth.9

In the protocol designed for water birth, the Australian Government also asserts that all health workers involved are responsible for any information given to women candidates in each provider’s water birth techniques.

Data, which is provided, should be accurate and up to date .10 Patients have many birth choices to consider making informed consent important when choosing water birth. 7,8,9

In general, preparing the mother for waterbirth does not differ much than preparing the mother for conventional birth.

A conducive environment for the prospective mother during water birth strongly supports the success of this program. The role of the assisting family is important as well in the preparation of childbirth. 11

Patient Selection

Water birth is generally given to the term pregnant woman with no complications.10, 12

Confinement terms for water birth:

  1. Low-risk pregnancy
  2. No vaginal, urine, or skin infection
  3. Vital sign within normal limits and infants CTG normal (baseline, variability, acceleration)
  4. Warm water is used for relaxation and pain management after cervix dilatation of 4-5 cm or more.
  5. Patients cooperative with birth attendant instruction, including a possible exit from the pool if necessary.

Criteria / Indications 10, 13.14

  1. It is a mother’s choice
  2. Normal pregnancy > / 37 weeks
  3. Single fetus with head presentation
  4. No use of drugs-sedative
  5. Spontaneous broken membranes < 24 hours
  6. Non-clinical criteria such as staff and equipment
  7. No pregnancy complications such as pre-eclampsia, uncontrolled blood sugar level, etc.
  8. Normal heart rate
  9. Clear amniotic fluid
  10. Spontaneous childbirthing or after using misoprostol or pitocin
  11. There is no bleeding. It is difficult to assess the loss of blood in water birth due to the lack of attendant experience in water birth. If that be the case, some service providers may prefer to deliver the placenta outside of the pool.

Contraindications 10,13,16

  1. Infection that can be transmitted through the skin and blood.
  2. Febrile mother or other evidence of infection.
  3. Herpes genitalis. Herpes is very easily transmitted through water.
  4. Abnormal fetal heartbeat.
  5. Abnormal vaginal bleeding.
  6. HIV, Hepatitis.
  7. Macrosomia.
  8. Meconium. A light or medium meconium can be said normal in childbirth. However if thick meconium appears in the water, the attendant should clear or help the patient out from water birth pool.
  9. Breech presentation of the baby.
  10. Multiple pregnancy.
  11. Babies who are estimated to be born premature (2 weeks more or before the time of confinement)
  12. Condition that needs continual monitoring unless there is a condition where the waterproof transducers (Doppler) are available.

Technical Aspects

Provision facilities and infrastructure of water birth in general can be adjusted with the place where water birth will be implemented.

Clinics, hospitals and even at home can also be good settings for water birth as long as criteria is still met and the rules and guidelines are followed.

Based on the above, the technical procurement of water birth that must be owned: 16

Technical procurements on hand:

  1. Confinement pool
  2. Water pump: electric water pump works more quickly than hand water pump
  3. Water pipe: choose a quite long water pipe in order to reach water sources and confinement pool.
  4. Faucet hose adapter: choose the adapter that is easily removed and not part of other circuits.

Other suggested equipment:

  1. Debris removal Net. It is normal for the mother to defecate during second stage of labor, in this case, use debris removal net to retrieve and dispose of it.
  2. “Y” pipe adapter and End Cap to connect between Faucet adapter and water pipe.
  3. Hand-held Mirror. Many women in labor who start to push in hands and knees position. This position makes the mother unable to see the baby when the baby is born. By placing the mirror at the bottom of the foot and the light to the mirror, the mother can see the birth process easily.
  4. The lamp can be placed in the water directed to the mirror at the top so that the mother can see the birth process easily
  5. Thermometer in the water. This device helps care providers to regulate water temperature.
  6. Submersible water sucker. Portable sucker pipe means that pipes can be used to drain the pond without the need to find a power source.
  7. Gloves of sufficient length to protect care providers while listening to the heart of the baby or checking dilatation.

In addition to standard equipment, some equipment below should also available in the water birth service: 12

  1. Maternal thermometer.
  2. Waterproof Doppler.
  3. Water resistance cloth.
  4. Additional that can help the mother out of the pool if necessary.
  5. Knee bolster, cushion, low stool and birthing balls should preferably be provided so that care providers are comfortable (Burn & Kitsinger 2001).

In 1995, Alderdice et al., conducted research on 4494 retrospective confinement in the water made by midwives in England and Wales. They reported the deaths of 12 infants, 51 cases of illness (respiratory infection).

However, the researchers concluded that no evidence found that confinement in the water is less safe than conventional labor 20 American Academy of Pediatrics 19 mentions that the safety and effectiveness of the baby in water birth cannot be confirmed.

Meanwhile, the British Pediatric Surveillance8 mention deaths or the need for special handling of babies born in water from years 1994-1996.

Some reports of cases21 mention that there were sepsis of the baby because of pool contamination, but the numbers cannot be proven scientifically. Based on that, the procedure to maintain pool water cleanliness needs more attention by each provider of water birth.

Below are the procedures and guidelines quoted from the Australian government for the water birth: 12.

  1. Clean portable swimming pools with disposable liners
  2. In the practice of swimming pools, spa regimens should use solvents in jets, sucker pipes, pipes and filters. Between births the tub must be cleaned by using liquid Chlorine each time it is used.
  3. Cleaning fluid is a liquid that is commonly used in hospitals or who has received approval by the local organization.
  4. Birth tubs should be dried under the air.
  5. Birth tubs before re-use should be cleaned again.
  6. Reinforced with routine maintenance.
  7. Routine testing is done for Legionella in hospital water supply where the test bacteria is adjusted to the recommendations of local government.

Controversy about water birth has been around since 1723. It cannot be not separated from the various research results that have been conducted by various researchers in various countries.

In fact this method is widespread and popular in the community. Use of analgesia during labor is low and comfort earned by the mother during childbirth is a strong attraction for the candidates and the water birth services.

Quality improvement and standardization of services in accordance with guidelines is the key to comfort and safety of this technique. Therefore, researchers should continue to seek accurate information so that hey may develop reasonable guidelines for water birth. Valid research, of course, is supported by good research methods and controls.

Hopefully in the future with the increasing number of randomized and controlled trials we will be able to improve the scientific assessment of water birth. In summary water birth can be one of the best methods of childbirth sought after by expecting family’s aiming for baby’s gentle landing on earth.


  1. Grunebaum A, Chervenak Fa. In the baby or the bathwater: which one should be discarded?J. Perinatat.Med 2004; 32:306-7
  2. Alfirevic,Z,et al. Immersion in water during labour and birth (Royal college of obstetricians and gynaecologist/Royal college of midwives joint statement no.1).2006;{5 screen}.. Available from: URL: http:/ Accessed: May 12,2009
  3. Duley, L.M.M. Birth in Water (RCOG Statement no.1).2001:{3 screens}. Available from: URL:
  4. Palmer, J. In water during labour and birth. 2001; {4 screens}. Available from: URL:
  5. Chapman,B. Water birth protocol: Five North Island hospital in NeW Zealand. College of midwives Journal.2004; 30:20-4
  6. Singh U, Schereiner A, Macdermott R, Johnston D, Seymour J, Garland D,et al.Guidelines for Water Birth within the midwifery led unit and at home (Dartford and Gravesham-NHS Trust).2006;{4 screen}. Available from: http//www.darentvalley . Accessed: May 13,2009
  7. Parker PC, Boles RG. In pseudomonas otitis media and bacterimia following a water birth. Pediatrics 1997; 99:653-4
  8. True about water risk and complications. 2006; {2 screen}. Availabel from: http://www.water birth risk often involve various problems with breathing.htm
  9. Gilbert,RE, Tookey, P.A. In Perinatal mortality and morbidity among babies delivered in water: surveillance study and postal
  10. Garland,D, Choo,YP, and birth –The royal college of midwives.2000;{4 screens}. Available from:URL: . Accesed: May 14,2009
  11. M (Ref not provided – ed. Active Birthpools)
  12. Policy-First stage labour in water. Government of South Australia.2005;{9 screens}. Available from: . Accesed: May 14,2009
  13. Guidelines for water at OHSU. Oregon health and sciences university water birth guidelines.2001;{1 screen}. Available from: URL: .
  14. Water birth – Wikipedia, the free encyclopedia (Wikipedia foundation,, INC). 2007; {8 screens}. Available from: URL: http:/ . Accessed: May 14,2009
  15. Anonymus. Waterbirth guidelines.2009;{1 screen}. Available at: URL: http://www.yourwater
  16. Roberts D. In guidelines for the use of water during labour and in the event of deliveries. Liverpool womens hospital NHS trust. 2002;{4 screen}. Available at:URL: http://www . Accessed: May 14,2009
  17. Burns E, Kitzinger S. Midwifery guidelines for use of water in labour. Oxford Centre for Health Care Research and Development, Oxford Brookes University, 2001
  18. Garland D. Waterbirth-an attidute to care. Cheshire: Books for Midwives,1995
  19. Batton, DG,et al. Underwater births. Pediatrics,2005; 115;5:1413-14
  20. Alderdice F, Renfrew M, Marchant S,et al. Labour and birth in water in England and Wales. BMJ 1995;310:837
  21. Vochem M, Vogt M, Daring G. Sepsis in a newborn due to pseudomonas aeruginosa from contaminated tub bath. BMJ 2001;345:378

MIDIRS: The use of water during childbirth

20 November 2015:

Since the early 1980s use of immersion in water during labour and birth has been increasingly promoted to enable women to relax, help them cope with pain, and maximise their feelings of control and satisfaction1-4.

In 1992 the House of Commons Health Committee recommended all hospitals provide the option of a birthing pool where practicable5. Currently few women give birth in water but the option of immersion or showering during the first stage of labour is commonly available.6-8

Although problems have arise which have been attributed to water use, the results of the most formal evaluations have not clearly associated water use with harmful outcomes for mother or baby 3,9-13.

The lack of robust evidence of harm or benefit means that childbearing women and health practitioners alike are subject to conflicting opinion about the usefulness and safest of water, particularly for birth.

However, a recent observational study over a nine year period concluded that ‘waterbirth was associated with low risks where obstetric guidelines were followed’16.

At present in the UK there is no reliable measurement of the rate of birth in water.
A national survey of maternity units in the UK in 2002 found that 63% (216/342) had a birthing pool8; 67% (228/342) reported having at least one midwife trained to provide support for women giving birth in water and 36% (121/342) said that at least half of the midwives working in their unit were trained to support birth in water.

How is water used during labour?

Water use ranges from informal, for example when a woman in early labour decides to get into her bath at home before going to hospital, to formal use in a specially designed birthing pool. Informal use in a domestic bath or shower is often initiated by a woman herself to help her cope at home before her labour is well established.

Formal use implies either that a woman has actively chosen to use water as part of her plan for labour and/or childbirth or that a health professional, usually a midwife, has suggested use during established labour.

Why water use is promoted

Use of immersion in water during childbirth has largely been driven by pregnant and birthing women17 and supported by midwives. During the first stage of labour it is advocated to shorten labour and help a woman relax and cope with contractions, feel more in control, and to reduce intervention by health professionals3,18-21.

During the second stage, proponents use it to allow perineal tissues to stretch spontaneously, birth to occur with minimum intervention, and to provide the baby with a gentler transition into extra-uterine life. Expectant management of the third stage is likely if a woman is in water.

Limitations on water use

Many health professionals consider that water use during the first stage of labour in uncomplicated pregnancy is unlikely to harm the mother or baby22,23, whilst others have concerns about water use at any point in labour14.

Local clinical guidelines may restrict water use to women considered at ‘low’ obstetric risk7, and other aspects of care may be prescribed, for example when and how to monitor the temperature of the water, the degree of cervical dilatation at which to begin its use24, and whether the immersion is considered safe for all stages of labour6,25.

Problems associated with possible risk of infection or cross infection caused by amniotic fluid, blood, and faeces have been described26-28 and some hospitals have restricted use of birthing pools to women who have tested HIV negative during pregnancy29.

However, at a multi-disciplinary consensus meeting held in London in 1996, it was agreed that mandatory HIV testing for prospective users of birthing pools could be an extreme reaction to the perceived risks and that high standards of pool hygiene would be an appropriate way forward30. Local infection control guidelines should cover the use of water pools25,31 and procedures to minimise risk of cross infection13, 32.

It has been suggested that high water temperature can cause serious changes in feto-maternal haemodynamic regulation and fetal thermoregulation33. It has been reported that fetal tachycardia can be reduced by cooling the water34 and most providers and clinical guidelines specify a temperature range within which the water should be maintained during the first and second stage of labour7,35.

The prospect of a woman giving birth in water can cause anxiety about how to deal with unexpected emergencies such as shoulder dystocia, the need to avoid the baby inhaling water, or being unaware that the umbilical cord has been severed11.

Despite the fact that it denies women choice about birth, one response has been to limit water use to first stage only6. Development of agreed clinical protocols to deal with unexpected complications25 and providing training which allows3 staff to achieve relevant competencies is key to enabling real choice for women about use of water.

There are theoretical risks of increased blood loss, retained placenta, or water embolism, and professional advice is often to conduct the third stage out of water25.

Because water adds to the difficulty of estimating blood loss accurately, it has been proposed that blood loss would be more appropriately estimated as being either more or less than 500ml36 and that the overall physical condition of the woman should be used as the most important indicator to assess the impact of any bleeding37.

In summary, although not universally accepted, first stage water use is less controversial than immersion for the second or third stage of labour22,23,38.

The research evidence

The effects of water use during the first stage of labour on maternal and fetal outcomes have been evaluated in several randomised controlled trials4,9,10,12,13,39 with sample sizes ranging from 60 to 123934.

The use of water has been shown to reduce the rate of augmentation40; however, no trial has been large enough to measure the effect of water use on important neonatal outcomes such as perinatal death or other serious neonatal or maternal morbidity.

In addition, there has often been significant cross-over between study groups4,12, reducing the likelihood of identifying clear differences between women allocated to water use and those not.

A systematic review of eight trials41 indicated a statistically significant reduction in the use of pain relief with no such significant difference in the rate of operative deliveries or in neonatal outcomes.

It concluded that while the use of water in the first stage of labour can be of benefit to some women, there is no evidence at present to support or not support a woman’s choice to give birth in water.

Retrospective comparison has been made of women who have used water with those who have not42,43.

However, there are considerable difficulties in interpreting such studies because of the possibility that the results are inherently biased.

In the same way, findings of cohort studies which suggest benefit for water use in terms of pain relief and increased rate of cervical dilatation44-47, or those which indicate differences in rates of maternal and neonatal infection48-50, are also open to criticism.

A recent study16 compared neonatal and maternal morbidity and mortality for spontaneous singleton births that took place in water or on land.

This was an observational study over a nine year period and data were obtained through standardised questionnaires for 9,518 births, of which 3,617 were waterbirths and 5,901 landbirths.

Statistically significant differences were identified between the two groups; women who gave birth using water were less likely to suffer serious perineal trauma, use no analgesia and have a lower blood loss than women in the landbirth group.

Maternal and neonatal infection rates were the same for both groups, but more landbirth babies had neonatal complications requiring transfer to an external NICU.

During the study, there were neither maternal nor neonatal deaths related to spontaneous labor.

The authors acknowledge the potential bias that could arise from the self-selection issue but argue that this is well accounted for in the analysis.They conclude that waterbirths are associated with low risks for both mother and child when obstetrical guidelines are followed.

Another study51 based in a centre for low risk women was a retrospective case review over a five year period of 1355 births in water.

When compared with land births over a corresponding period, women who gave birth in water had significantly fewer episiotomies with no evidence of a corresponding rise in lacerations, a reduction in the length of the first stage of labour, no increase in the risk of acquired infection or aspiration pneumonia and considerably lower levels of analgesia use.

Neonatal condition assessed by arterial cord blood pH, base excess and birth weight showed no differences.The authors conclude that this represents a realistic option for women at low risk of complications.

Many reports about water use are case series1,20,52-62 and focus on perceived benefits of water use for the mother, her baby and birth attendant.

These include shorter labour52, less use of pharmacological analgesics46,53, less intervention by care givers19, lower rate of perineal trauma60-62, and increased satisfaction with the experience of labour and birth54.

By contrast, some case reports have highlighted serious problems such as fetal overheating33,34, neonatal sepsis28, near drowning63 or death64.

Overall, reviews of the evidence21,23,65,66 conclude that appropriately large-scale research is still required to evaluate rigorously the physiological effects13, clinical outcomes, and economic impact of water use.

What we don’t know

The current evidence about water use remains quite heavily dependent on case series and comparison studies that include varying sized samples.

Therefore, reliable evidence about efficacy and effectiveness is still equivocal67.

  • Outstanding issues which require evaluation include:
  •  is water use causally associated with an increase in perinatal mortality or serious perinatal morbidity?
  •  at what dilatation should a woman be advised to begin water use?
  •  does the size or shape of the water container affect outcomes?
  •  if water has an effect on important physical/psychological outcomes for mothers or babies, are there particular women who should avoid using water during labour?
  •  to what extent immersion in water affects the length of labour?

Implications for maternity

Water use during the first stage of labour is offered by the majority of maternity care provider units in the UK and most offer support for water birth8.

Introduction of, and sustained suppor t for, water use may have considerable implications for service governance68.

However, not all costs fall to providers of care; a substantial cost burden is likely to be borne by labouring women themselves during informal use in domestic baths and showers or by hiring specially designed pools for use in their home or in a maternity unit.

Most maternity units have installed a water pool for use in labour8 and although installation and maintenance of a specially designed pool in a maternity unit involves obvious financial cost, this may be offset if there is a reduction in analgesia and anaesthetic use44.

There is evidence that formal water use means that at least one midwife will be in constant attendance during the first stage of labour and that at least two will be in attendance for birth7.

This level of staffing may be difficult to sustain and may have implications for equity of care for women who do not use water22.

Clear strategies for the training, preparation and support of staff who offer use of water during labour are recognised as essential7,25,31,37,44.

Key components of these include clarification of the roles of different maternity health professionals, multi-disciplinary development of local protocols, development of guidelines for clinical practice, and short-term secondment of midwives to learn alongside practitioners skilled and experienced in water use.

Implications for practice

Women may choose to use immersion in water during labour and/or birth. Midwives and other maternity care workers should therefore be knowledgeable about the evidence in terms of potential advantages and disadvantages.

Given the current quality of reliable evidence, effective practice is likely to be informed and influenced substantially by shared experience and personal observation.

Disproportionate weight may therefore be placed on perceived disadvantages or advantages and credibility given to outcomes which may not be associated causally with water use.

Practitioners should be alert to the evolving evidence base which underpins the use of water.

  •  Immersion in water during childbirth is a care option women may wish to choose and which health professionals have a responsibility to discuss and support using clear and balanced information.
  •  As with any labour or birth, it is essential to maintain systematic, contemporaneous records and to monitor and record routine observations about the well-being of the mother and the fetus. These data should be used to audit care and gather information about outcomes.
  •  Water temperature should be measured regularly using a thermometer and recorded.The water temperature should be comfortable for the woman and should be not more than 37°C during the first stage of labour and between 36-37°C in the second stage.
  •  Maternal faeces, meconium and blood clots should be removed from the water using a sieve, and effective cleaning of pools before/after use should be carried out to minimise risk of infection or cross-infection.
  •  Birth in water: the baby should be born fully submerged and be brought gently and without delay to the surface so that he/she can make their first respiratory efforts in air.
  •  Comprehensive, large scale research is required to address questions about the safety and effectiveness of using water during labour and/or birth.

Reproduced from Midirs 2005, last revised Jan 2005, review date Jan 2007. Informed Choice is supported by the Royal College of Midwives and the National Childbirth Trust.


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The effect of waterbirth on neonatal mortality and morbidity: a systematic review protocol

8 December 2015:

Rowena Davies, RM, BA 1, 2

Deborah Davis RM, PhD1, 2

Melissa Pearce RM/RN, BNurs, GDipMid, GCertMid, MMidwifery2, 3

Nola Wong, RM/RN2, 3

1. Nursing and Midwifery, Faculty of Health, University of Canberra

2. The Australian Capital Regional Centre for Evidence Based Nursing and Midwifery Practice: an affiliate centre of the Joanna Briggs Institute

3. Centenary Hospital for Women and Children, Canberra

Corresponding author: 

Rowena Davies

Review question/objective

The objective of this research is to systematically review the evidence regarding the effect of waterbirth, in comparison to land birth, on the mortality and morbidity of neonates born to low risk women.


Waterbirth and water immersion in labor are two distinct phenomena; however they are often confounded. Some women use water immersion in labor as a strategy to manage their labor pain but leave the bath prior to the birth of their baby.

As the name implies, however, waterbirth occurs when a baby is born underwater. This can happen either intentionally or accidentally, for example when a woman uses water immersion during labor and remains in the water to birth her baby.

Although the definitions of waterbirth and water immersion are simple to separate, descriptions of their use during a woman’s labor are often merged. 1,2

Given this, it is not surprising that research attempting to describe the benefits and risks of both water immersion and waterbirth is interwoven.

In many instances, discussion of waterbirth is confused by focusing on the benefits of water immersion for the woman and the risks of waterbirth to the neonate, two separate issues.

Water immersion in labor

Water immersion in labor has been used by many generations of women and is common practice in many birthing suites.3 Current research describes benefits for women using water immersion in labor including: increased relaxation4, pain relief5,6, maximized maternal satisfaction7, reduced length of labor2,3,5,8,9, reduced intervention3,10,11, increased spontaneous birth 12,13 and reduced first and second degree perineal tears.13,14

The buoyancy enabled by the water allows women to move easier during labor and potentially optimizes labor progress.3,6 Water immersion may also be associated with improved uterine perfusion, less painful contractions and a shorter labor.3,15,16

A Cochrane systematic review of eight trials comparing water immersion in labor with controls showed that water immersion resulted in a significant reduction in epidural analgesia use (478/1254 versus 529/1245; risk ratio [RR] 0.90; 95% [Confidence Interval [CI] 0.82 to 0.99, six trials]), a reduction in duration of the first stage of labor (mean difference -32.4 minutes; 95% CI -58.7 to -6.13, seven trials) with no difference in assisted vaginal birth (RR 0.86; 95% CI 0.71 to 1.05, seven trials), caesarean sections (RR 1.21; 95% CI 0.87 to 1.68, eight trials), use of oxytocin infusion (RR 0.64; 95%CI 0.32 to 1.28, five trials), perineal trauma (intact perineum, 236/678 versus 200/659, RR 1.16, 95% CI 0.99 to 1.35, five trials) or maternal infection (15/647 versus 15/648, RR 0.99, 95% CI 0.50 to 1.96, five trials). 5 There have been no studies that have identified any adverse effects of water immersion in labor for the woman or the neonate.


The benefits to women of using water immersion in labor are evident. However, the practice of birth underwater remains controversial and the debate polarized, with research providing conflicting information and mixed results.

As a result of this confusion, many birthing units in Australia provide water immersion in labor as an option for women; however, implementing waterbirth policies remains a slow and complex process.17,18

The trend of waterbirth

The first recorded waterbirth occurred in France in 1803.19 After laboring for 48 hours, an exhausted woman used a warm bath and birthed a healthy baby.1 In the early 1980s, waterbirths became more popular as water immersion was promoted to help women relax and cope with their labor.20, 21

Currently, few women birth their baby underwater; however water immersion in labor is commonly available.20 Baths and birthing pools were integrated into the United Kingdom’s mainstream maternity units in 1992 after the House of Commons Health Committee recommended that all women have access to water for labor and birth.12

Their national practice guidelines also support the use of baths and birthing pools in labor.22 Within Australia, 14 of 19 birthing centres provide bath facilities.23 Further, waterbirth tends to be supported by midwives as it represents a birthing option congruent with midwifery philosophy.7,24

Concerns about waterbirth

In an uncomplicated pregnancy, water immersion is unlikely to harm the woman or her baby.5 Given this, many birthing units will restrict water immersion in labor to women with a low risk pregnancy.

Regarding waterbirth, commentators have developed a list of contraindications; however, due to a paucity of research in this area, this is based largely on opinion.18 Even so, the option to waterbirth remains restricted to women with a low risk pregnancy. Individual birthing units develop specific waterbirth protocols suiting their own circumstances and existing policy.

In a review of the evidence on waterbirth, Young and Kruske (2013) identified five main areas of concern: a perceived risk of neonatal water aspiration, neonatal and maternal infection, neonatal and maternal thermo-regulation, skills of attending midwives and emergency procedures in the event of maternal collapse. They concluded there was no evidence supporting these concerns.25

Although the practice of waterbirth has been linked to increased risk to the neonate1, 26-28 there is no high level evidence available to support this issue.20,29 The association between waterbirth and adverse neonatal outcomes comes largely from case reports. 28,30,31

These highlight the potential risks to the neonate from waterbirth, including: neonatal respiratory distress, neonatal infection, umbilical cord avulsion, hyponatremia, hypoxic ischemic encephalopathy, fetal thermoregulation and water embolism.1,26,28,32,33

There are also numerous articles providing commentary about a perceived lack of adequate research and potential disregard for adverse neonatal outcomes following waterbirth.18,32, 34-36 Both case studies and commentary are at risk of author bias and represent a low level of evidence upon which to build waterbirth policy and protocol.

The above neonatal outcomes, as described within the literature, will form the basis of the reviewers search and discussion concerning potential neonatal outcomes following waterbirth.

Current evidence and policy

Simpson (2013)37 conducted a systematic review of neonatal outcomes following waterbirth; however, only two randomized controlled trials (RCT), two systematic reviews and case reports were reviewed.

A number of observational studies have been conducted on waterbirth but these were not included.37Also, no meta-analysis was conducted. The Cochrane systematic review by Cluett and Burns (2009) was similarly limited to RCTs. 5 Another systematic review, conducted in 2004, searched for complications that could be associated with waterbirth and was not limited to RCTs.1

They reviewed 16 articles and concluded that waterbirth may be associated with complications that are not seen with land birth, however, outcomes from water immersion and waterbirth are confounded.1 The quality and rigor of this review has also been called into question.35

There are two known RCTs comparing outcomes after waterbirth and land birth: an Iranian study of 106 women38 and a pilot study conducted in the UK.29 Both trials are small and therefore offer limited evidence. Woodward and Kelly (2009) reported that a larger RCT is possible and acceptable to women; however no further trial has been conducted hence raising concerns over feasibility.29

Published guidelines for health practitioners argue that there is insufficient evidence to guide waterbirth practice. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists offer a cautious review, suggesting that there is little evidence of waterbirth offering any benefits and advise caution when interpreting any current studies due to small sample sizes.39

The American College of Obstetricians and Gynecologists (2014) state that waterbirth “should be considered an experimental procedure that should only be performed within the context of an appropriately designed clinical trial with informed consent”40(p.914). However, it is unlikely that a RCT could ethically be conducted on this practice.

Other protocols agree that there may be no benefit, but argue that there is also no adverse effects directly attributed to waterbirth. A joint statement released by the Royal College of Obstetrics and Gynaecology (RCOG) and the Royal College of Midwives (RCM) support women laboring in water while acknowledging the lack of evidence supporting waterbirth and the rarity of complications.41

The Queensland Normal Birth guidelines also discuss waterbirth stating there is no evidence of increased adverse effects for the woman or fetus; however they acknowledge there is inadequate evidence to either support or not support, a woman’s choice to birth underwater.42

Young and Kruske (2012) confirm that Australia’s individual state policies lack contemporary, high quality evidence and do not encourage or provide guidance for women or their health care providers. 43

The current state of opinion and evidence of the benefits and risks of waterbirth for the neonate requires a thorough systematic review to be conducted. Current evidence is contradictory and the lack of robust systematic evidence regarding waterbirth allows the growth of conflicting opinion about its safety.

Given the scarcity of reliable evidence, anecdotal shared experiences and personal observation has influenced policy and practice. 20 A review of current literature focusing on high level evidence and maintaining clear and thorough search guidelines is needed to advance our understanding of the effect of waterbirth on neonatal outcomes.


Waterbirth; neonatal outcomes; mortality; morbidity

Inclusion criteria

Types of participants

This review will consider studies that include low risk, healthy, pregnant women who labor and birth spontaneously, at term (37-42 weeks), with a single baby in a cephalic presentation.

Low risk pregnancies are defined as pregnancies with an absence of comorbidity or obstetric complication, such as maternal diabetes, previous caesarean section birth, high blood pressure or other illness. Women may be experiencing their first or subsequent pregnancy. The baby must also be well and without any comorbidity or complication.

Types of intervention(s)/phenomena of interest

The intervention of interest is waterbirth. The comparator is land birth. Women and their babies must be cared for by qualified maternity healthcare providers throughout their labor and birth. The birth setting must be clearly described but can include homebirth, hospital birth or birth center, either freestanding or attached to a hospital.

Types of outcomes

This review will consider studies that include the following neonatal outcome measures:

1. Neonatal mortality- stillbirth or neonatal death within 28 days of birth

2. Neonatal resuscitation or Respiratory Distress Syndrome within 24 hours of birth

3. Neonatal sepsis/infection, including fever and other infection markers, as defined within any studies, within seven days of birth

4. APGAR scores at one, five and ten minutes

5. Admission to Neonatal Intensive Care Unit or Special Care Nursery, including length of stay

6. Cord pH values – arterial and/or venous taken immediately following birth

7. Cord avulsion

8. Hyponatremia

9. Hypoxic ischemic encephalopathy

10. Birth injury

Types of studies

This review will consider studies that compare neonatal outcomes for both waterbirth and land birth including randomized controlled trials, quasi-experimental studies, prospective and retrospective cohort studies. Descriptive studies that do not include a comparator will be excluded.

Search strategy

The search strategy aims to find both published and unpublished studies. A three step search strategy will be utilized in this review. An initial search of MEDLINE and CINAHL will be undertaken followed by an analysis of the text words contained in the title and abstract, and of the index terms used to describe the article.

A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference lists of all identified reports and articles will be searched for additional studies.

Studies published in English within the last 15 years (from 1999) will be considered for inclusion. This ensures that retrieved studies will provide recent, up-to-date evidence that will reflect more contemporary practice and policy.


1. Pinette MG, Wax J, Wilson E. The risks of underwater birth. Am J Obstet Gynecol.2004; 190(5): 1211-5. PMid:15167820

2. Thoeni A, Zech N, Moroder L, Ploner F. Review of 1600 water births. Does water birth increase the risk of neonatal infection. J Matern Fetal Neonatal Med.2005; 17(5): 357-61. PMid:16147851

3. Otigbah CH, Dhanjal MK, Harmsworth G, Chard T. A retrospective comparison of water births and conventional vaginal deliveries. Eur J Obstet Gynecol Reprod Biol.2000; 91(1): 15-20.

4. Maude R, Foureur M. It’s beyond water: stories of women’s experience of using water for labour and birth. Women Birth.2007; 20(1): 17-24. PMid:17174165

5. Cluett ER, Burns E. Immersion in water in labour and birth. Cochrane Database for Systematic Reviews.2009; (2): doi: 10.1002/14651858.CD000111.pub3.

6. Jones L, Othman M, Dowswell T, Alfirevic Z, Gates S. Newburn M. Pain management for women in labour: an overview of systematic reviews. Cochrane Database of Systematic Reviews.2012. doi: 10.1002/
7. Richmond H. Women’s experience of waterbirth. Pract Midwife.2003; 6(3): 26-31.


8. Richmond H. Theories surrounding waterbirth. Pract Midwife.2003; 6(2): 10-3.


9. Cortes E, Basra R, Kelleher CJ. Waterbirth and pelvic floor injury: a retrospective study and postal survey using ICIQ modular long form questionnaires. Euro J Obstet Gynecol Reprod Biol.2011; 155(1): 27-30. PMid:21185644

10. Lukasse M, Rowe R, Townend J, Knight M, Hollowell J. Immersion in water for pain relief and the risk of intrapartum transfer among low-risk nulliparous women: secondary analysis of the Birthplace national prospective cohort study. BMC Pregnancy Childbirth.2014; 14(60): doi: 10.1186/1471-2393-14-60.

11. Mollamahmutoglu L, Moraloglu O, Ozyer S, Su FA, Karayalcin R, Hancerlioglu N The effects of immersion in water on labor, birth and newborn and comparison with epidural analgesia and conventional vaginal delivery. J Turk Ger Gynecol Assoc.2012; 13(1): 45-9. PMid:24627674 PMCid:PMC3940223

12. Burns E, Boulton M, Cluett E, Cornelius V, Smith L. Characteristics, interventions, and outcomes of women who used a birthing pool; a prospective observational study. Birth.2012; 39(3): 192-202. PMid:23281901

13. Henderson J. Labouring women who used a birthing pool in obstetric units in Italy: prospective observational study. BMC Pregnancy Childbirth.2014; 14(17): doi: 10.1186/1471-2393-14-17.

14. Pagano E, De Rota B, Ferrando A, Petrinco M, Merletti F, Gregori D. An economic evaluation of water birth: the cost-effectiveness of mother well-being. J Eval Clin Pract.2010; 16(5): 916-9. PMid:20590979

15. Garland D. Waterbirth in the United Kingdom. Midwifery Today Int Midwife.2000; 54(1): 26.


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


17. Dahlen HG, Dowling H, Tracy M, Schmied V, Tracy S. Maternal and perinatal outcomes amongst low risk women giving birth in water compared to six birth positions on land. A descriptive cross sectional study in a birth centre over 12 years. Midwifery.2013; 29(1): 759-764. PMid:22884894

18. Veltman L, Doherty D. Safety and underwater birth? What every risk manager should know. Journal Healthc Risk Manage.2013; 32(4): 16-24. PMid:23609973

19. Embry M. Observation sur un accouchement termaine dans le bain. Ann Soc Med Prat Montpellier; 5(1): 13.
20. MIDIRS. The use of water during childbirth. MIDIRS.2005; Retrieved from: Accessed 4.3.14.
21. Odent M. Birth under water. Lancet.1982; (2): 1476-7.
22. National Institute of Clinical Excellence. Intrapartum Care: care of healthy women and their babies during childbirth. London.2007; NICE. Retrieved from Accessed 6.3.14.
23. Laws PJ, Lim C, Tracy S, Sullivan EA. Characteristics and practices of birth centres in Australia. Aust N Z J Obstetr Gynaecol.2009; 49(3): 290-295. PMid:19566562

24. Meyer SL, Weible CM, Woeber K. Perceptions and practice of waterbirth: a survey of Georgia midwives. J Midwifery Womens Health.2010; 55(1): 55-9. PMid:20129230

25. Young K, Kruske, S. How valid are the common concerns raised against water birth? A focused review of the literature. Women Birth.2013; 26(2): 105-9. PMid:23182130

26. Carpenter L, Weston P. Neonatal respiratory consequences from water birth. J Paediatr Child Health.2012; 48(1): 419-423. PMid:22085259

27. Gilbert RE, Tookey PA. Perinatal mortality and morbidity among babies delivered in water: surveillance study and postal survey. BMJ.1999; 319(7208): 483-487.

28. Kassim Z, Sellars M, Greenough A. Underwater birth and neonatal respiratory distress. BMJ.2005; 330(1): 1071-2. PMid:15879398 PMCid:PMC557235

29. Woodward J, Kelly SM. A pilot study for a randomised controlled trial of waterbirth versus land birth. BJOG.2004; 111(6): 537-45. PMid:15198780

30. Cohain JS. Waterbirth and GBS. Midwifery Today Int Midwife.2010; (96): 9-10.


31. Schafer R. Umbilical cord avulsion in waterbirth. J Midwifery Womens Health.2014; 59(1): 91-4. PMid:24588881

32. Davies MW. Water births and the research required to assess the benefits versus the harms. J Paediatr Child Health.2012; 48(9): 726-729. PMid:20598065

33. Eckert K, Turnbull D, MacLennan A. Immersion in water in the first stage of labor: a randomised controlled trial. Birth.2001; 28(2): 84-93. PMid:11380379

34. Batton DG, Blackmon LR, Adamkin DH, Bell EF, Denson SE, Engle WA. Underwater births. Pediatrics.2005; 115(1): 1413.


35. Keirse M. Challenging Water Birth? How Wet Can It Get? Birth.2005; 32(4): 318-322. PMid:16336374

36. Schroeter K. Water births: a naked emperor. Pediatrics.2004; 114(3): 855-8. PMid:15342864

37. Simpson KR. Underwater birth. J Obstet Gynecol Neonatal Nurs.2013; 42(5): 588-94. PMid:24004064

38. Chaichian S, Akhlaghi A, Rousta F, Safavi M. Experience of water birth delivery in Iran. Arch Iran Med.2009; 12(5): 469-471.
39. Royal Australian and New Zealand College of Obstetricians And Gynaecologists. Warm water immersion in labour and birth. College Statement.2011. Retrieved from . Accessed 24.4.14.
40. American College of Obstetricians and Gynecologists. Immersion in water during labour and delivery. Committee opinion No. 594. Obstet Gynecol.2014; 123(4): 912-5. PMid:24785637

41. Royal College of Obstetricians and Gynaecologists and Royal College of Midwives. Immersion in water during labour and birth. Joint Statement.2006. London: Author.
42. Queensland Maternity and Neonatal Clinical Guidelines Program. Normal Birth. 2012. Retrieved from Accessed 3.3.14.
43. Young K, Kruske S. Water immersion in Queensland. Evidence, Access and Uptake.2012; Queensland Centre for Mothers and Babies: University of Queensland. Retrieved from Accessed 21.5.14.

MANA and CfM Issue Joint Position Statement on Water Birth

18 February 2016: Midwives Alliance

The MANA and CfM Joint Position Statement on Water Immersion During Labor and Birth is a position paper written for a broad audience including midwives and other birthcare professionals, consumers, doulas, childbirth educators, and policy makers.

It is co-authored by the Midwives Alliance of North America and Citizens for Midwifery.

A year of collaborative work has produced a great educational tool that gives concise access to the research and the wisdom of experience that documents the safety, benefits and recommendations for success.

With over 80 citations, including the new study “Maternal & Newborn Outcomes Following Immersion During Waterbirth” by Bovbjerg, Cheyney and Everson, which utilized data from the MANA Statistics project, and research by waterbirth activist Barbara Harper, the position paper is a reference guide to the evidence for the safety of water immersion during labor and birth.

How does the new study using data from the MANA Statistics project help us better understand waterbirth?

The research of Bovbjerg, Cheyney and Everson helps to dispel some of the more publicized concerns about the safety of waterbirth to the baby, including drowning, cord avulsion and respiratory distress.

No deaths in over 6500 water births were attributable to being born under water. There was also no additional risk of maternal infection or hemorrhage.

The MANA Stats study showed that 35% of over 18,000 home and birth center births occurred in water, demonstrating that the midwives contributing to MANA Stats have considerable experience attending and monitoring births in water.

The experience level of the practitioner may be an important factor in the safety of waterbirth.

6,521 waterbirths, including 13 sets of twins, 29 breeches and 327 VBACs, were compared with 10,252 mothers who did not choose waterbirth, making this the largest comparative study on waterbirth to-date.

Additionally, this is the first large waterbirth study of a US population, with its unique healthcare system and demographics.

While the ACOG/AAP Committee Opinion of April, 2014, not recommending water immersion for birth, acknowledged the limitations of the available research on waterbirth, this large US study fills that gap and gives us the best evidence to-date on the safety of birthing in water.

“Maternal & Newborn Outcomes Following Immersion During Waterbirth” by Bovbjerg et al, was published Jan. 20, 2016 in the Journal of Midwifery & Women’s Health.

JMWH has generously agreed to make this research article open access, so midwives, birth workers, and consumers can read it without needing to buy a subscription to the Journal.

What else can we learn from the MANA/CfM Joint Position Statement?

Evidence and experience show us that mothers choose waterbirth for several reasons.

They report feeling more relaxed, in control, able to move more freely, and, notably, relief from pain.

Especially considering the risks of pharmacologic pain management such as epidural and spinal anesthesia, water immersion during labor and birth may be safer for mother and baby.

“In addition, because water immersion facilitates normal physiologic birth it may also be associated with other beneficial health outcomes for mother and baby, including decreased need for intervention during labor and reduced incidence of surgical/instrumental delivery.”

As in all healthcare and birthcare decisions informed consent/refusal and shared decision making with your care provider is key to determining what is best for each family.

The Joint Position Statement can help in these ways:

  • describes the benefits of water immersion for mother and baby,
  • suggests how these benefits may improve outcomes for families of color,
  • addresses consumer choice and shared decision making,
  • considers client values and individual needs and,
  • lists factors that promote safety and success.

The practical and professional pearls of wisdom make the Factors that Promote Safety and Success section an invaluable tool when considering and planning a waterbirth and we are pleased to be able to share them with you.

The conclusion:

Many families consider water immersion during labor and birth a valuable option.

Current research and experience show waterbirth to be safe for mothers and babies and may provide benefits to both.

“MANA and CfM support the use of water immersion during labor and birth, and believe it should be made available to birthing families across all settings.

MANA and CfM encourage all care providers to become educated about the safe use of water immersion during labor and birth, and to engage in a shared decision making process when discussing the option of water immersion with their clients.” (quote from the statement)

The authors of the joint position statement are:

Jill Breen, CPM, CLC; Justine Clegg, CPM, LM, MS; Nasima Pfaffl, MA, President CfM; Amy Smith, CPM

Thanks also to the consultants on the statement:

Barbara Harper, RN, CD, CCE; Holly Horan, MA; Jennie Joseph, LM, CPM, CEO of Commonsense Childbirth, Inc.; Indra Lusero, JD, MA; Jeanette McCulloch, IBCLC; Shafia M. Monroe, MPH, DEM, CDT, President and CEO of the International Center for Traditional Childbearing (ICTC).

Evidence Based Guidelines for Midwifery Led Care in Labour: Birth Environment

Practice Points

Ensure that pregnant women receive high quality care throughout their pregnancy, have a normal childbirth wherever possible, are involved in decisions about what is best for them and their babies, and have choices about how and where they give birth (DH 2004).

Respect for a woman’s wishes and her involvement in decision making is essential to her care in pregnancy and labour (NICE 2007; DH 2004). The birth plan should be discussed in full with the midwife looking after the woman in labour.

Hospital is an alienating environment for most women, in which institutionalised routines and lack of privacy can contribute to feelings of loss of control and disempowerment (Lock and Gibb 2003; Steele 1995).

The studies by Green et al. (1990) and Simkin (1992) found that control, or lack of it, was important to the women’s experience of labour and their subsequent emotional well-being.

Trials have demonstrated the benefits to women of having a low-risk, midwife-led area as an alternative to the conventional labour ward (Birthplace in England Collaborative Group 2011; Hodnett et al. 2010; Hatem et al. 2008; Byrne et al. 2000; Hodnett 2000; Waldenstrom 1997; Hundley et al. 1994; McVicar et al. 1993).

The non-labour ward or radically modified environment is associated with lower rates of analgesia, augmentation and operative delivery, as well as greater satisfaction with care and positive effect on care givers (Birthplace in England Collaborative Group 2011; Hodnett et al. 2010; Hodnett et al. 2009).

Midwives should be aware of the influence the physical environment has on their practice (Hodnett et al. 2010).

2 Evidence Based Guidelines for Midwifery-Led Care in Labour ©The Royal College of Midwives 2012

Birth Environment

The environment in which a woman labours can have a great effect on the amount of fear and anxiety she experiences.

Hospital is an alienating environment for most women, in which institutionalised routines and lack of privacy can contribute to feelings of loss
of control (Lock and Gibb 2003; Steele 1995).

Brown and Lumley (1994) found that the technology and intervention that has now become commonplace on many labour wards was implicated in women’s dissatisfaction with labour. Increased anxiety brought on through loss of control can interfere with the normal effective physiology of labour (Steele 1995).

The studies by Green et al. (1990) and Simkin (1992) found that control,
or lack of it, was important to the women’s experience of labour and their subsequent emotional wellbeing.

It is not easy to separate the influence of the model of care
from the physical environment on the outcomes.

Hodnett et al. (2010) discuss the effect that the physical environment can have on practice, within the supportive social model of care.

In 2009, Hodnett et al. undertook a pilot study aimed to investigate the impact of the physical environment on women and practitioners by making simple but radical modifications to a hospital labour room, which included the removal of the standard hospital bed and the addition of equipment to promote relaxation, mobility,
and calm.

The women were then randomly allocated either the modified or typical
labour room.

Though the pilot was small in numbers, the outcomes indicated that the physical environment modification had a positive effect on women and care providers.

The philosophy of mobilisation in active labour was increasingly supported in the modified environment (Hodnett et al. 2009).

RCM (2008) Birth Centre Standards for England Standard 7.6 sets criteria of
‘An environment that protects and promotes women’s privacy and dignity, respecting

their human rights and provides facilities to maintain adequate nutrition and hydration in labour.’

Respect for a woman’s wishes, and her involvement in decision-making is essential to her care in pregnancy and labour (DH 2007, DH 2004).

National Service framework maternity policy (DH 2004) pledged that service should “ensure that pregnant women receive high quality care throughout their pregnancy, have a normal childbirth wherever possible, are involved in decisions about what is best for them and their babies, and have choices about how and where they give birth” and the choice aspect remains within NHS future plans (DH 2010).

It would appear that women have better physical and emotional labour outcomes when they are involved in the decision making (Hodnett et al. 2010).

Green et al.’s study (1990) found that good information was important to a woman’s birth experience and also to her subsequent emotional well-being.

The decision-making must extend to the woman’s choice of companion(s), who should be made to feel welcome in the labour ward.
Evidence Based Guidelines for Midwifery-Led Care in Labour ©The Royal College of Midwives 2012

Birth Environment

Birth planning is a continuous part of antenatal care.

This requires a focussed discussion about place of birth, at which ‘women should receive clear, unbiased advice and be able to choose where they would like their baby to be born’ (DH 2007; DH 2004).

The recent Birthplace in England study (Birthplace in England Collaborative Group 2011) looked at safety of births planned in 4 different settings: home, freestanding midwifery units, alongside midwifery units and obstetric units for women with straightforward pregnancies.

It found that birth is safe wherever it takes place but there is a small but increased risk of adverse outcome for the neonate for nulliparous women associated with planned home birth.

The outcomes for multiparous or in other midwife led birth environments were the same. The study did not look into reasons for this and further exploration into the variation is required.

However, this information needs to be included in the discussions with women antenatally. The ‘birth talk’ and associated birth plan are essential opportunities for women and midwives to share information (NICE 2007).

The birth plan should be discussed in full with the midwife looking after the woman
in labour.

Women often find it difficult to ask questions, so midwives need to encourage them to do so, and to act as advocate for the wishes expressed (Kirkham 1986).

Trials have demonstrated the benefits to women of less intervention and more mobility, in having a low-risk, midwife-led area as an alternative to the conventional labour ward (Birthplace in England Collaborative Group 2011; Hodnett et al. 2010; Hatem et al. 2008; Byrne 2000; Hodnett 2000; Waldenstrom 1997; Hundley et al. 1994; McVicar et al.

1993). The philosophy behind the provision of such units is to provide a ‘homely’ environment, where women can take more control and labour is managed with minimal intervention (Hodnett et al. 2010; Hundley et al. 1994).

It has also been found that women who give birth in low-tech, midwife-led facilities, e.g. home or birth centres, require less pharmacological analgesia (Hodnett et al. 2010; Chamberlain et al. 1997; Skibsted and Lange 1992).

Hodnett et al.’s (2010) review found that the alternative birth setting environment is associated with lower rates of analgesia, augmentation and operative delivery, as well as greater satisfaction with care.

There was a non-statistically- significant trend towards higher perinatal mortality in the home-like setting, and the reviewers conclude that ‘an over-emphasis on normality’ may lead to delayed recognition of or action regarding complications.

Walsh (2004) has challenged this conclusion from his own experience and suggests that midwives who work in this environment are ‘astute assessors of normal birth’ and highly skilled practitioners, who are active in performing repeated emergency drills.

Hodnett et al. (2010) found, in their comparison of alternative and conventional labour and birth environments, that staff working in the ‘alternative’ settings all shared philosophies and guidelines that valued midwifery-led care.

The study was not able to explore the separate influences of the physical environment and models of care such as, for example, continuity of caregiver, but concluded that the impacts of midwifery-led care and the nature of the birth setting are fundamentally interdependent in the chain of cause and effect leading to more positive outcomes.

Evidence Based Guidelines for Midwifery-Led Care in Labour ©The Royal College of Midwives 2012

Birth Environment

Brown S, Lumley J (1994) Satisfaction with care in labour and birth: a survey of 790 Australian women. Birth 21(1): 4-13

Birthplace in England Collaborative Group (2011) Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: The Birthplace in England national prospective cohort study. British Medical Journal 343: d7400

Byrne J, Crowther C, Moss J (2000) A randomised controlled trial comparing birthing centre care with delivery suite care in Adelaide. Australia Australian and New Zealand Journal of Obstetrics and Gynaecology 40(3): 268-74

Chamberlain G, Wraight A, Crowley P (1997) Homebirths: The Report of the 1994 Confidential Enquiry by the National Birthday Trust Fund. Carnforth, Lancashire: The Parthenon Publishing Group

Department of Health (DH) (2010) Equity and Excellence: Liberating the NHS. London: HMS

Department of Health (2004) National Service Framework for Children, Young People and Maternity Services. London:DH

Green JM, Coupland VA, Kitzinger S (1990) Expectations, experiences and psychological outcomes of childbirth: a prospective study of 825 women. Birth 17(1): 15-24

Hatem M, Sandall J, Devane D et al. (2008) Midwife-led versus other models of care for childbearing women. Cochrane Database of Systematic Reviews, Issue 4. Chichester: John Wiley & Sons

Hodnett E, Downe S, Edwards N, et al. (2010) Alternative versus conventional institutional settings for birth. Cochrane Database of Systematic Reviews, Issue 9. Chichester: John Wiley & Sons

Hodnett ED, Stremler R, Weston JA, et al. (2009) Re-conceptualizing the hospital labor room: the Place (Pregnant and Laboring in an Ambient Clinical Environment) pilot trial. Birth 36(2):159-66

Hodnett ED, Hatem M, Sandall J, et al. (2008) Continuity of caregivers for care during pregnancy and childbirth. Cochrane Database of Systematic Reviews, Issue 4. Chichester: John Wiley & Sons

Hodnett ED (2000) Continuity of caregivers for care during pregnancy and childbirth. Cochrane Database of Systematic Reviews 2000, Issue 1. Chichester: John Wiley & Sons

Hundley V, Cruikshank F, Lang G, et al. (1994) Midwife managed delivery unit: a randomised controlled comparison with consultant led care. British Medical Journal 309(6966): 1400-1404

Kirkham MJ (1986) A feminist perspective in midwifery. In Webb C (ed.) Feminist practice in women’s health care. Chichester: John Wiley

Lock L, Gibb H. (2003) The Power of Place. Midwifery 19(2): 132-139
McVicar J, Dobbie G, Owen-Johnston L, Jagger C, et al. (1993) Simulated home delivery:

a randomised control trial. British Journal of Obstetrics and Gynaecology 100(4): 316-33
National Institute of Clinical Excellence (NICE) (2007) Intrapartum care: management and delivery of care to women in labour. London: NICE

The Royal College of Midwives (RCM) (2008) Standards for birth centres in England: a standards document. London: RCM

Simkin P (1992) Just another day in a woman’s life? Part 2 Nature and consistency of women’s long-term memories of their first birth experiences. Birth 19(2): 64-81

The effects of immersion in water on labor, birth and newborn and comparison with epidural analgesia and conventional vaginal delivery

Leyla Mollamahmutoğlu,1 Özlem Moraloğlu,1 Şebnem Özyer,1 Filiz Akın Su,1 Rana Karayalçın,1 Necati Hançerlioğlu,1Özlem Uzunlar,1 and  Uğur Dilmen2


To document the practice of labour in water, to assess the effects of water immersion during labor and/or birth (labour stages 1, 2 and 3) on maternal, fetal and neonatal wellbeing and to compare the outcomes and safety with conventional vaginal deliveries and deliveries with epidural analgesia.

Material and Methods

Two-hundred and seven women electing for waterbirth (n=207) were compared with women having conventional vaginal deliveries (n=204) and vaginal deliveries with epidural analgesia (n=191). Demographic data, length of 1st, 2nd and 3rd stage of labor, induction and episiotomy requirements, perineal trauma, apgar scores, NICU requirements and VAS scores were noted.


The 1st stage of labor was shorter in waterbirths compared with vaginal delivery with epidural analgesia but the 2nd and 3rd stage of labor were shortest in patients having waterbirth compared with conventional vaginal delivery and vaginal delivery with epidural analgesia.

Patients having waterbirth had less requirement for induction and episiotomy but had more perineal laceration. All women having waterbirths had reduced analgesia requirements and had lower scores on VAS.

There was no difference in terms of NICU admission between the groups. Apgar scores were comparable in both groups. There were no neonatal deaths or neonatal infections during the study.

The study demonstrates the advantages of labor in water in terms of reduction in 2nd and 3rd stage of labor, reduction in pain and obstetric intervention such as induction or amniotomy.


In 1983, Odent published the results of the first hundred water births in The Lancet (1). It was postulated that anxiety and pain may trigger a stress response during labour (2) leading to reduced uterine activity and dystocia (3). Labouring in water may overcome this stress response by aiding relaxation and relief of pain (4).

Zanetti-Daellenbach et al. revealed that water deliveries performed in a selected low risk collective needed less analgesia had a shorter duration of first and second stages of labour, a lower episiotomy rate and were not associated with any adverse maternal or fetal outcome (5).

The advantages of immersion in water during labour and/or birth include reduced pain, increased functional diameter of the true pelvis, increased quality of contractions, increased release of endorphins, decreased need for opiates, increased movement for the mother as well as improved positioning in different stages of labour (6).

There are also studies that have reported the disadvantages associated with water birth which include maternal and neonatal infections, as well as the possibility of respiratory problems for the newborn (7, 8).

Cluett and Burns in a review of 11 trials concluded that water immersion during the first stage of labour reduced the use of epidural/spinal analgesia, but there was limited data for other outcomes related to water use during the first and second stages of labour (9). They also stated that there was no evidence of increased adverse effects on the fetus/neonate or woman from labouring in water (9).

The aim of this study is to document the practice of labour in water, to assess the effects of water immersion during labour and/or birth (labour stages 1, 2 and 3) on maternal, fetal and neonatal wellbeing and to compare the outcomes and safety with conventional vaginal deliveries and deliveries with epidural analgesia.

Materials and Methods

In a prospective clinical trial, the interview and observation techniques were used to study 610 pregnant women who were admitted to Zekai Tahir Burak Women’s Health Education and Research Hospital, between June 2007 and September 2008.

Women electing for water birth (Study Group 1, n=207) were compared with vaginal deliveries with epidural analgesia (Study Group 2, n=191) and women having conventional vaginal deliveries (Control, n=204).

The pregnant women were given comprehensive information on water birth before they were asked to participate in the study. Ethical approval was obtained from the local research ethics committee prior to the study, and written informed consent obtained from all patients.

This study was conducted in accordance with the basic principles of the Helsinki Declaration.

The inclusion criteria were gestational age between 37–42 weeks, no previous history of cesarean section, intact membranes, absence of placental abruption or placenta previa, no malpresentation, normal sized single fetus, and normal results of fetal wellbeing tests. The pregnant women with medical or obstetric risk factors were excluded (n=8).

Women presenting on the delivery suite with painful uterine contractions had an initial cervical assessment. This was taken as the onset of the active phase of labour in all groups. They were assigned to control and two study groups. The women were put in a standardized warm water pool which is large enough to allow the pregnant women move freely.

At the time of delivery the water temperature was set to between 37 and 37.5ºC so that the baby was not stimulated to breathe underwater by the cooler temperature of the pool. Fetal heart monitoring was performed at regular intervals with Doppler or NST. In the second stage of labour, care was taken to ensure the controlled delivery of the head of the fetus.

The newborn was placed gently in the mother’s arms within seconds but without rushing and then the cord clamped and cut. Delivery of the placenta and the membranes was completed outside the pool. After the delivery, the pool was emptied and cleaned with antiseptic solution. Cultures were taken for the determination of pathogenic bacteria.

Demographic data, length of 1st, 2nd and 3rd stages of labor, requirement for induction and episiotomy, perineal trauma, apgar scores, neonatal intensive care unit (NICU) requirements and visual analog scale (VAS) scores were noted on a questionnaire.

The women evaluated their birth experience with the VAS (10 cm long VAS from 1 to 10 corresponding to the amount of pain felt by the woman with number 1 for no pain and with number 10 for dreadful pain).

Statistical analysis

Data were evaluated by SPSS for Windows release 15.0 (Chicago Inc.). To compare groups, we used the Chi-square test for categorical variables, Oneway ANOVA and Bonferroni tests for continuous variables that have normal distribution, Kruskall-Wallis oneway ANOVA for continuous variables that have no normal distribution.

As described, variables, frequencies and percentages were given for categorical variables, Mean±standard deviations and median were given for continuous variables. Alpha=0.05 was accepted as a statistically significant value.

In order to detect±2 percentage point difference in VAS scores between groups, for having alpha=0.05, power=0.97, it was predicted that approximately 200 subjects for each group should be taken (NCSS-Pass Pocket Program was used) (Chow SC et al.) (10).

The study groups consisted of 207 water births (Group 1) and 191 vaginal deliveries with epidural analgesia (Group 2), the control group (Group 3) of 204 patients gave birth by the conventional vaginal delivery method at the hospital. The women in the three groups were matched with respect to age, BMI and gestational age (Table 1).

There were 276 primigravidae and 326 multiparous women having water births (Table 2). The mean age of the women were 26.2±5.1, 26.1±4.5 and 25.5±5.1 respectively (Table 1). The mean cervical dilatation at admission in both group 1 (5.3 cm) and group 2 (4.6 cm) was not significantly different from group 3 (4.7 cm).

The duration of the 1st stage of labour was shortest in the conventional vaginal delivery group whereas the duration of the 2nd and the 3rd stages of labour were shortest in the water birth group (Table 1).

There was a highly significant reduction in the induction and episiotomy requirements in the water birth group (Table 1). VAS scores were the lowest in the water birth group, so there was less analgesia requirement (Table 1).

Conversely, the perineal laceration rate was higher in the water birth group, however most of these lacerations were minimal. Systolic and diastolic blood pressures seem to be lower in the water birth group, however the differences were not clinically significant. The decrease in hemoglobin levels as an indication of blood loss during labour were not statistically significant.

The birthweight of the infants were highest, however Apgar scores were slightly lower in the water birth group. There was no difference in the rates of admissions to the NICU between the groups (Table 1). There were no documented neonatal infections. There was no adverse perinatal outcome or neonatal deaths. All the babies were born in good condition.

When primigravidas and multiparous women having water birth are considered (Table 2), the 1st stage of labour is longer in both groups compared with controls, however the 2nd and 3rd stages of labour were the shortest in both primigravidas and multiparous women labouring in water compared with controls. The need for induction and episiotomy for both primigravidas and multiparous women was lowest in water birth group compared with others.

Perineal laceration rates were higher in both groups compared with controls. VAS scores were lowest in the water birth group in both primigravidas and multiparous women. Apgar scores were slightly lower in the water birth group, however NICU admission rates were not statistically different in the water birth group for both primigravidas and multigravidas.


Water births have rapidly become one of the most popular birth methods. There is evidence of use of water immersion as a therapeutic medium for physical and psychological illnesses by the Chinese, Egyptians, Japanese and Assyrians, as well as Greeks and Romans (9).

Water immersion during labour, including birth, used for relaxation and pain relief, has a long history. In 1995, the first international water birth conference was held in London, followed by many researches and conferences.

The positive physiological effects of hydrotherapy can facilitate the neurohormonal interactions of labour, reducing pain, and potentially facilitates the progress of labour (11, 12). Water immersion may be associated with improved uterine perfusion, less painful contractions and a shorter labour with fewer interventions (13–15).

Several reports have shown that water immersion shortens the process of labour (1, 15), however some others found no significant difference for the duration of the 1st stages of labour (13, 16–20). The present study also demonstrates that the 1st stage of labour is not shortened by immersion in water in either primigravidas or multigravidas.

Cammu et al., Eckert et al., Rush et al. and Woodward et al. provided data on analgesia and anesthesia use in their studies and found that there was a significant reduction in the incidence of analgesia and anesthesia use among women placed in water during the first stage of labour (16, 17, 19, 20).

In the present study, we have shown that VAS scores indicating the pain felt by the women were lowest among women having water birth, even lower than the women labouring with epidural analgesia. In agreement with these studies, we observed that immersion in water greatly reduces the pain and need for additional analgesia.

Labouring in water has been found to reduce stress hormones and cathecolamines which inhibit oxytocin and labour progress (9). In our study, the duration of the second stage of labour was found to be shorter in water births, consistent with the results of studies of Chaichian et al. and Otigbah et al. (6, 21).

The fetus may be more likely to adopt a more relaxed and flexed position, because the mother can easily explore different positions to maximise her pelvic diameters (22).

The duration of the 3rd stage of labour, which is the delivery of the placenta, is also significantly reduced after water births. This minimizes amount of blood loss during this period.

The lower blood loss in water births can also be explained by the hydrostatic pressure in the pool, by the less severe lacerations or possibly by a facilitated control of the third stage of labour.

In the study, patients having waterbirth had less requirement for obstetric interventions such as induction and episiotomy but had more perineal lacerations. However, the lacerations in water birth group were less severe than those in epidural analgesia and conventional delivery group.

Otigbah et al. found that primigravidas having water births had less perineal trauma and the overall episiotomy rate was 5 times greater in the control group, but overall, more women having water births had perineal tears (21). On the other hand, there are studies which show no difference in perineal trauma (23, 24).

The reason why women having water births had more tears may be explained by the difficulty in accessing the women’s perineum during birth, resulting in more perineal trauma.

However, the widespread belief that with episiotomies 3rdand 4th degree lacerations are avoided is open to question, because in our study episiotomy rates were lowest after water births, and the lacerations were minimal.

There are some concerns about water birth for the fetus. These are thermoregulation during labour, infection and onset of respiration at birth. As the water temperature of the pool does not exceed the maternal body temperature, fetal hyperthermia and associated cardiovascular and metabolic disturbances will not occur (25). None of the newborns in our study took its first breath in water.

This has been explained by the diving reflex which shows that, when the face or especially the glottis comes in contact with fluid, respiration movements are inhibited. Aspiration will occur only when the diving reflex fails, because of anesthesia or severe asphyxia or because of the inappropriate pool temperature.

When we consider neonatal infection, several reported comparative studies, cohort studies and audits report no increased risk of infection to the newborn (5, 19, 21). This is also confirmed by the study that there were no documented neonatal infections.

Overall, water birth does not cause an increased risk of adverse effects to the fetus/newborn.

In conclusion, the study demonstrates the advantages of water birth in terms of reduction in the duration of the 2nd and 3rd stages of labor, reduction in pain and obstetric intervention such as induction or episiotomy.

Labouring in water significantly reduces pain and the requirement of epidural/spinal analgesia.

It is a management approach which contributes positively to maternal physiological and psychological health by reducing the augmentation which is known to increase the risk of uterine hyperstimulation and fetal hypoxia and by reducing the obstetric interventions which are associated with lower maternal satisfaction.

There is no increased adverse effects to the fetus or labouring women.

Water birth may be an alternative birth method that can be offered in selected patients.


Conflict of interest

No conflict of interest was declared by the authors.


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Response to joint ACOG and AAP Committee’s opinion regarding birthing pool use

May 2014

Response to joint American College of Obstetricians and Gynecologists (ACOG), and American Academy of Pediatrics (AAP) Committee’s opinion regarding birthing pool use during labour and waterbirth

A recent publication, ‘Immersion in water during labor and delivery’, by the US Committee on Obstetric Practice representing the American College of Obstetricians and Gynecologists and American Academy of Pediatrics, recommended that waterbirth should be ’considered an experimental procedure’ and only performed in the context of a randomised controlled trial 1.

Whilst this committee’s opinion accurately highlighted the lack of definitive randomised controlled trial (RCT) evidence (level 1) for waterbirth, citing the Cochrane review 2, its reignition of the debate about the ‘safety and efficacy’ of waterbirth was disappointingly biased, and partially incorrect. For example, it concludes that waterbirth ‘has not been associated with maternal or fetal benefit’, yet there is no evidence to suggest that it presents a greater risk than land birth for women who experience a straightforward pregnancy, or their newborn.

The committee opinion also indicated that most of the literature in support of waterbirth comprises ‘retrospective reviews of a single center experience, observational studies using historical controls [….] often in publications that are not peer reviewed’ 1. Geissbuehler and Eberard’s observational study, which included 3,617 waterbirths was in fact prospective and published in a peer reviewed journal 3.

Moreover, the committee made no mention of two additional prospective observational studies: one involving a UK sample of 8,924 women, which included 5,192 waterbirths 4, and the second study involving an Italian sample of 2,505 women, of whom 1,519 had a waterbirth 5. These studies were also published in peer reviewed journals.

There is reliable level 2 evidence showing an association between waterbirth and positive outcomes for women and their newborn. The UK study found that women, particularly nulliparae who had a waterbirth were more likely to experience a normal birth compared with women who used a birthing pool only during the first stage of their labour 4.

Normal birth is a composite outcome defined as including a spontaneous labour onset, no epidural and a spontaneous vaginal birth with no episiotomy 6, and its incidence has been identified as a marker of quality care 7.

This is an important finding in the context of a global initiative to reduce the overuse of intrapartum interventions and operative delivery.

Safety outcomes for women at low risk of childbirth complication showed no increase in the incidence of infection, or primary postpartum haemorrhage, and a reduction in operative delivery 3-5, 8. Findings of a reduced incidence of intrapartum interventions such as requirement for augmentation, pharmacological analgesia, and episiotomy indicate that waterbirth is also efficacious 3-5.

Results for neonates born in water to women at low risk of childbirth complication show no associated risk of increased morbidity or mortality in relation to infection, resuscitation, or NICU admission compared to land birth 3-5, 8. The committee opinion paper cited a small number of case studies that reported newborn ‘near-drownings’ following waterbirth.

This term has been used to describe a phenomenon whereby some babies born in water present with respiratory distress in the hours following birth; a condition that may self-resolve or require admission to NICU for oxygen therapy. In the term infant, this is usually caused by delayed lung aeration, and known as transient tachypnoea of the newborn (TTN) 9.

The large prospective observational studies, and a paediatric survey of 4,032 waterbirths found no increase in the incidence of transient tachypnoea of the newborn compared with land birth 3-5, 10.

Waterbirth studies have reported a low incidence of umbilical cord snap during waterbirth 4, 10, 11. However, data have not been collected for this complication during land birth, which currently precludes making comparisons.

As with all aspects of childbirth, and irrespective of high quality care provision, unforeseen adverse events shall always occur, and waterbirth is no exception.

It is incumbent upon caregivers to ascertain that it poses no added risk, or harm. Birthing pool use has gained in popularity among women and midwives in several countries, particularly among those working in midwifery led care settings. Further level 1 research is required to examine a number of factors in more detail.

For example, we need to explore further if waterbirth has the potential to facilitate normal birth. It is also necessary to compare the incidence of umbilical cord snap at, and transient tachypnoea of the newborn following waterbirth versus land birth. Another important area that we need to know more about is the acceptability of waterbirth to women and midwives.

Available level 2 evidence for waterbirth provides an important basis to inform pertinent outcome measures for a future randomised controlled trial.

In the meantime however, there is no reliable available evidence to indicate that waterbirth presents an increased risk factor compared with land birth for women who experience a straightforward pregnancy. There is therefore no reason to deny them the choice of using a birthing pool during the first or second stage of their labour in their planned place of birth.

Maternal choice in childbirth is a human right 12.

The right for women to choose is endorsed by the UK’s position statement regarding birthing pool use during labour and waterbirth 13, as reiterated in a recent BMJ news item in response to this Committee Opinion from the US 14.


1.      American College of Obstetricians and Gynecologists, American Academy of Pediatrics. Immersion in water during labor and delivery. Committee opinion Number 594, April

2014  [cited 2014 26th March]; Available from:

2.      Cluett E, Burns E. Immersion in water in labour and birth Cochrane Database Syst Rev  2009 22nd October 2009 [cited 2013 20th January ]; CD000111.pub3.]. Available from:

3.      Geissbuehler V, Stein S, Eberhard J. Waterbirths compared with landbirths: an observational study of nine years. Journal of Perinatal Medicine. 2004; 32(4): 308-14.

4.      Burns EE, Boulton MG, Cluett E, Cornelius VR, Smith LA. Characteristics, Interventions, and Outcomes of Women Who Used a Birthing Pool: A Prospective Observational Study Birth. 2012; 39(3,): 192-202.

5.      Henderson J, Burns EE, Regalia AL, Casarico G, Boulton MG, Smith LA. Labouring women who used a birthing pool in obsteric units in Italy: prospective observational study. BMC Pregnancy Childbirth. 2014; 14(1): 17.

6.      Maternity Care Working Party, Royal College of Obstetricians and Gynaecologists, Royal College of Midwives. Making normal birth a reality; consensus statement.  2007  [cited 2011 9th September]; Available from:

7.      Dodwell M. Normal birth as a measure of the quality of care.  2010  [cited 2011 20th February]; Available from:

8.      Thoeni A, Zech N, Moroder L, Ploner F. Review of 1600 water births. Does water birth increase the risk of neonatal infection? J Matern Fetal Neonatal Med. 2005; 17(5): 357-61.

9.      Carpenter L, Weston P. Neonatal respiratory consequences from water birth. J Paediatr Child Health. 2012; 48(5): 419-23.

10.     Gilbert R, Tookey P. Perinatal mortality and morbidity among babies delivered in water: surveillance study and postal survey. British Medical Journal. 1999; 319(7208): 483-7.

11.     Cro S, Preston J. Cord snapping at waterbirth delivery. British Journal of Midwifery. 2002; 10(8): 494-7.

12.     Birthrights. Human rights in maternity care.  2014  [cited 2014 10th April]; Available from:

13.     Royal College of Obstetricians and Gynaecologists, Royal College of Midwives. Immersion in water during labour and birth, Joint statement No.1.  2006  [cited 2014 10th April]; Available from:

14.     McCarthy M. Underwater births should be limited to clinical trials, says US pediatric and obstetrics panel. .  2014  [cited 2014 27th March]; 348:[Available from:

Diving in: a dip in the water for labour and birth policy debate

Megan Cooper RM, BHSc (Honours), Jane Warland RM, PhD Helen McCutcheon RM, PhD.


Water immersion for labour and birth is becoming an increasingly attractive option for women.

However, with what has been described as a paucity of research, water immersion policies appear to lack the evidence to ensure confidence in their use, safety in their implementation and importantly, acknowledgement of women’s autonomy to utilise water for labour and birth irrespective of their perceived ‘risk’.

In touching on the difficulties experienced by maternity care providers working within a system largely dominated by a ‘risk adverse’ paradigm, the following paper will highlight the shortfalls of research surrounding water immersion for labour and birth and the difficulties of utilising policies informed almost entirely by this research.

The current paucity of rigorous evidence and the difficulties faced by maternity care providers facilitating the option, highlights that greater emphasis needs to be placed on gaining a substantial evidence-base to inform future water immersion polices with more weight given to both observational data and anecdotal experience.

Future research should focus on both quantitative and qualitative aspects of water use for labour and birth to ensure that policies incorporate the required risk/benefit analysis, the opportunity for shared and informed decision-making and ultimately, the facilitation of woman-centred care.

Should we throw out the bath water?

For many women water immersion (WI) during labour and birth is an attractive and sought after option of care.

Despite the availability of literature surrounding WI for labour and birth many argue that high quality research with which to measure risks and benefits is still lacking.

As the option has become increasingly available, the development of policy to guide and inform care providers in the safe practice of WI for labour and birth has become necessary.

Consequently, policies appear to have been derived from what some describe as a less than substantive evidence-base (Cluett and Burns, 2009).

This has elicited debate as to whether the practice itself and therefore the policies currently informing the practice reflect the required foundational evidence to fulfill the ideal of evidence-based practice.

In touching on the current difficulties experienced by care providers working within in a ‘risk averse’ system the following paper will briefly explore WI for labour and birth, highlight the perceived shortfalls of research pertaining to its practice and discuss some of the difficulties of undertaking research at the level that many believe is required.

The role of qualitative research in informing the practice of labour and birth in water will also be examined with particular reference to the goal of woman-centred care and the need for policy that is reflective of a holistic evidence-base and supportive of women’s experience, satisfaction and choice.

The practice of water immersion for labour and birth

Despite common belief, WI for labour and birth is not a new phenomenon, with history dating back to the Egyptian Pharaohs and the Minoans of Crete (Mackey, 2001). In the 1960’s, Igor Charkovsky, a Russian midwife, began experimenting with the use of water for labour and birth after realising the positive physical and physiological effects of WI (Houston, 2010).

The 1980s saw Michel Odent, a well-known French Obstetrician and arguably the pioneer of modern water birth, establish the first birthing unit allowing women access to baths during labour, many of whom also went on to birth in water

(Houston, 2010). His observations and documented accounts of witnessing women immerse themselves in warm water allowed him to become a major influential figure in the global water birth movement and in the education of practitioners who facilitate the option of WI.

The advantages and benefits of WI during labour and birth have for the most part, not been thoroughly investigated through rigorous research.

Documented benefits include reductions in pharmacological pain relief (Eberhard et al., 2005, Otigbah et al., 2000, Benfield et al., 2001, Cluett and Burns, 2009), reduced blood loss and perineal trauma (Cluett and Burns, 2009) as well as facilitation of dysfunctional labour (Benfield et al., 2010, Cluett et al., 2004).

It has long been held that water immersion facilitates ‘normal’ birth and the latest prospective and descriptive cross sectional research findings provide support for this belief (Burns et al., 2012, Dahlen et al., 2012).

Burns et al. (2012) found that there was a higher frequency of spontaneous birth in nulliparas and greater rates of normal birth in both nulliparous and multiparous women when water was used during labour and/or birth. More specifically, of the 8924 participants almost 90 percent had a spontaneous birth and of these 5192 (58.3%) of women birthed in water.

Further support for benefits of water use come from Dahlen et al. (2012). They found in their Australian descriptive cross sectional study that women birthing in water had lower rates of major perineal trauma and PPH ≥ 500 milliliters when compared with those who used a birth stool on land.

Improved APGAR scores at five minutes were also noted for babies born into water compared to those whose mothers birthed in a semi-recumbent position on land although the authors note that they are unsure as to whether a semi- recumbent position was favoured by practitioners when there were fetal concerns, thereby potentially impacting on the results.

However, what is perhaps most important in terms of these findings is that there were no documented increased adverse outcomes for mothers who utiliszed water during labour and birth nor were there statistically significant increases in unfavourable outcomes for babies born into water.

Anecdotal experience supports these benefits further, with women suggesting greater levels of satisfaction, sense of autonomy and care providers observing less use of pharmacological pain relief and the facilitation of the fourth stage of labour, particularly in the initiation of breastfeeding.

Qualitative researchers have also found that women who birth in water feel protected, safe, relaxed and in control (Benfield et al., 2010, Maude and Foureur, 2007, Benfield, 2002).

For example, one New Zealand interpretive study, conducted by Maude and Foureur (2007), highlighted that WI provided a ‘sanctuary’ or environment whereby women felt protected and sheltered from intervention and interference. Participants also voiced a reduction in the fear of the birthing process and pain.

For many maternity care providers, water use for labour and birth is viewed as a method of providing women an alternative method of pain relief, ease of position changes and relaxation (Gilbert and Tookey, 1999, Meyer et al., 2010, Maude and Foureur, 2007, Woodward and Kelly, 2004, Stark and Miller, 2009).

Although evident throughout the literature, the observation and experience of maternity care providers is often challenged against minimal scientific proof, which to date, is still not entirely definitive.

Conversely, many continue to challenge the use of water for labour and birth claiming that it is neither normal nor natural for land living mammals to birth into water and that there exist too many associated ‘risks’ and adverse outcomes to mother and infant (Kassim et al., 2005, Mammas and Thiagarajan, 2009, Carpenter and Weston, 2011, Pinette et al., 2004).

The most recent published adverse outcomes pertaining to the use of water immersion during labour and birth come from Soileau et al. (2013) and Menakaya et al. (2012). Soileau et al. (2013) documents a neonatal infection and subsequent neonatal demise post a home water birth attributed to a maternal diarrheal infection in the week prior to birth. The infection believed to have been transmitted to the neonate after the mother defecated in the bath during labour.

This provides justification and support for the use of policy and/or guidelines in guiding practitioners in the facilitation of the option. Furthermore, its draws attention to the knowledge and understanding practitioners must attain in order to make decisions that ensure both maternal and neonatal wellbeing and safety when water is used.

Although Menakaya et al. (2012) did not assess maternal or neonatal infections in their retrospective design of 216 Australian women birthing in water, they noted that babies born into water showed a statistically significant difference in APGAR scores less than or equal to seven at one minute and as well as admission to Special Care Nursery (SCN) post birth in the water birth group.

Interestingly, three of the neonates transferred to SCN were admitted for feeding difficulties, issues which cannot be definitely linked to water immersion, one was admitted post a mild shoulder dystocia which presumably required the woman to be evacuated from the bath prior to birth and one for meconium aspiration, suggesting the presence of meconium which is commonly cited contraindication to birthing in water.

The remaining infants were admitted for resuscitation and an apneic event, which are also not unique to infants born in water.

One infant in the control group was admitted to the SCN and was transferred for respiratory distress requiring the longest stay of all infants admitted to the SCN. These findings are dissimilar to those of Mollamahmutoglu et al. (2012) who found no instance of neonatal infection and no significant difference in admission to the Neonatal Intensive Care Unit (NICU) when comparing infants who were born in water with those who were not. These findings are indicative of the inconsistent and contradictory findings pertaining to the use of water for labour and birth across the literature.

As a result, empirical research has failed to provide a definitive risk/benefit analysis relating to WI for labour and birth particularly in terms of maternal and neonatal infection, neonatal SCN/NICU admission, perineal trauma and the incidence of neonatal drowning and water embolism, as examples.

Furthermore, the ongoing reference to ‘potential’, ‘possible’ and ‘theoretical’ risks throughout the literature as well as throughout policy and guideline documents creates difficulty and uncertainty as to what actually constitutes risk and what is deemed as safe when WI is utilised for labour and/or birth (Kvach and Martonffy, 2012, Mackey, 2001, Pinette et al., 2004).

Watering down practice

Maternity care providers aim as far as possible, to deliver care which is women- centered (Carolan and Hodnett, 2007). Woman-centered care (WCC) incorporates the requirement of a woman making informed choices about all aspects of her care through the sharing of information (Leap, 2009).

Maternity care providers hold information that is vital to the woman but given the need to work within protocols and guidelines, may at times provide information to meet institutional and personal expectations and commitments resulting in what Carolan and Hodnett (2007) describe as “rule following and avoidance of responsibility”.

Although not necessarily a deliberate attempt to limit the information and options available to women, difficulties can arise as maternity care providers walk the fine line between meeting obligations as the woman’s advocate and the demands of institutional policies, guidelines and regulations.

Consequently care providers may forsake their role as the woman’s advocate, and instead support an environment that fosters informed compliance (Carolan and Hodnett, 2007).

Unfortunately the ideal of woman-centredness is often relinquished particularly as birth has become viewed a process that requires management and medical influence (Kitzinger, 2006, Davis-Floyd, 2001).

The burden of ‘proof’ and necessity of evidence to support or refute ‘alternative’ options irrespective of women’s requests and subjective knowingness that they work (Klein et al., 2006) has been significant in the debate surrounding water immersion for labour and birth.

Many of the benefits that water provides the labouring and birthing woman are also what may deter care providers from offering it as an option. Women and care providers alike, have suggested that water provides safety, sanctuary and distance from the rest of world allowing women a sense of control and ownership over their labour and birth (Maude and Foureur, 2007). However, this protection from intervention and intrusion

ultimately means that the contemporary methods of monitoring and gauging progress are no longer as accessible or practical. For many practitioners the inability to monitor and assess women as they normally would results in fear, not only of litigation and ‘what if’s’ (Garland, 1919), but also of the practice itself.

Combatting fear and anxiety could be as easy as encouraging care providers to witness women using water during labour and birth, but opinion and bias in disfavour of water immersion demands the current ‘gap’ in research be bridged.

Furthermore, ethical practice calls for practitioners to dissociate personal bias and views from their practice to ensure women’s autonomy and ability to exercise choice are not downplayed or absent in the facilitation of care (ANMC, 2008, ANMC et al., 2008).

This issue is further complicated by the political climate within which maternity care now exists. Despite many care providers supporting the implementation and practice of WI for labour and birth and having the capacity and accreditation to facilitate the practice, they may be restricted by the lack of institutional resources and support (Garland, 2011) and most commonly, policy that is derived from an aversion of risk and research that has yet to determine with any certainty the safety of using water for labour and birth.

WI for labour and birth, despite putting what feels like an ‘alternative’ slant on care, has the potential as a practice and option of care, to assist care providers such as midwives to re-recognize normal physiological birth and subsequently work towards fulfilling the ultimate goal of woman-centred care.

A drought of evidence?

Water birth, in particular, is frequently associated with perceived risks and dangers and for this reason its use continues to be challenged relative to safety implications for mother and infant as has previously been discussed (Pinette et al., 2004, Kvach and Martonffy, 2012).

The conundrum is yet to be resolved particularly given the perceived paucity of definitive evidence. Yet the option is becoming increasingly demanded and therefore available and as a result, policies are in place to guide care providers in its facilitation, which are probably based (at least in part) on this limited evidence.

Although a number of attempts have been made to undertake research at the ‘gold’ standard, randomised controlled trials (RCTs) examining WI for labour and birth have suffered from less than optimal sample sizes, selection bias or poorly controlled confounding factors in groups of low risk women who are usually highly passionate and motivated (Woodward and Kelly, 2004, Schroeter, 2004, Cluett and Burns, 2009).

This is evident in the latest Cochrane review that included only 12 suitable studies, and of these, only three examined the use of water during second stage of labour (Cluett and Burns, 2009). Further to this there is currently no population level data being collected anywhere in the world about outcomes of WI nor even how many women choose to use WI in labour and/or birth in water (Pinette et al., 2004).

Undertaking the recommended research on WI and birth particularly such as the RCT suggested by Davies (2010) is complicated given that randomising for such a study brings about ethical and moral concerns.

Hendrix et al. (2009) found this to be the case in their Dutch questionnaire-based study assessing women’s reasons for not participating in an RCT investigating home birth versus hospital birth. Eighty-four women indicated that they did not participate due to a concern that they would be randomised to the ‘wrong’ group.

Woodward and Kelly (2004) attempted to overcome women’s reluctance to participate in their pilot RCT comparing water birth with land birth by including a ‘preference arm’. Their results indicated there were no significant difference noted between women who were randomised and those who chose the ‘preference arm’ and therefore concluded that women would be happy to be randomised in future and similar trials.

However, criticism of this RCT highlights that their sample size was too small and therefore underpowered to determine safety, particularly given that only 10 women birthed in water. Further to this, Keirse (2005) challenges the validity and generalisability given the ‘preference arm’ and the bias that meant only 20 of the 60 women who had a strong preference for one of the two options, were allocated to their preferred option.

Subsequently, randomisation of women to options of care, which elicit both emotive and somewhat passionate views, such as the use of WI in labour and birth, is not ethically or practically feasible particularly where recruitment of large numbers would be required to determine with any certainty the morbidity and mortality of the intervention.

The proposed undertaking of this type of randomised research is further complicated by inconsistency across institutional policies in addition to funding, necessary infrastructure and available accredited staff (Garland, 2011).

Not only does this make it difficult to allow for the option and implementation of WI for labour and birth but it also inadvertently contributes to the lack of evidence in that accessibility is limited and therefore data on resulting outcomes, scarce. Furthermore, where it is consistently highlighted that high quality evidence is deficient, the question must be asked: who or what is informing the policies already in existence?

Initiating a wave of change

It is consistently highlighted that there is insufficient data to inform the practice of labour and birth in water, but is this really the case? It is clear that there is a paucity of evidence in terms of empirical investigation however volumes of anecdotal experience and observational data are available suggesting that water has significant and undeniable benefits to the women, and arguably to the baby.

Despite its availability, little weight is given to this valuable information, information that could be informing the movement forward and providing direction for future investigation of WI for labour and birth.

There is no denying that greater high level research would be advantageous to providing a definitive set of benefits and risks and therefore, greater insight into the relative safety of WI for labour and birth. However, is a RCT the right option?

The suggestion that rigorous evidence is needed to inform policies and guidelines with confidence and reliability could be attributed to what has been termed the ‘medicalisation’ of pregnancy and birth (Brubaker and Dillaway, 2009, Benoit et al., 2010) particularly where the measure of risk is at the forefront of maternity care facilitation.

However, in a risk-averse climate, adverse events whether recognised through well-constructed studies, auditing or anecdotal accounts, are generally the first to be documented so as to prompt review of practice.

Despite this, a search of the literature surrounding WI for labour and birth highlights very few documented adverse outcomes at any level of evidence and of those that are documented; the outcomes cannot always be definitively attributed to the use of water (Pinette et al., 2004, Cluett and Burns, 2009, Byard and Zuccollo, 2010).

What are readily available are anecdotal and observational accounts that suggest that WI has extensive benefits, not only to the woman but also to birth outcomes. It could therefore be argued that quantitative research alone is insufficient to provide answers to myriad of complexities, questions and queries relating to the practice of WI for labour and birth and therefore, insufficient when informing policies particularly where women choose to exercise self-determination and choice irrespective of their perceived risk.

Freeman and Griew (2007) touch on this in their review of one WI policy and its development. Their findings suggest that policy could further be enhanced by placing weight on the views and experiences of consumers and addressing the importance of informed and shared decision making.

This calls for attitudinal change not only to facilitate care that is woman-centred but also to ensure that women’s autonomy is factored into the development and implementation of policies underpinning practice.

The significance and value of qualitative evidence is slowly being realised, particularly in maternity care where WCC is the ideal. Despite this, empirical evidence is still commonly viewed as more rigorous and therefore more reliable.

This is none too clear in the hierarchies of evidence that fail to give weight to qualitative investigation (Spiby and Munro, 2009). However, as health care moves towards patient-centred models, or woman-centredness (Leap, 2009), as is the case in maternity care, there is the need for increasing weight to be also placed on experience and opinion particularly surrounding policy formation and care facilitation.

In light of this, a multi-faceted evidence-based approach to policy development and implementation of WI for labour and birth is likely to be advantageous.

However, before recommendations can be made, a critical analysis of existing policies and their development should occur in order to highlight whether the so-called scarcity of evidence poses difficulties for those involved in WI policy formation and to what extent policy facilitates and/or restricts water use practice and more importantly, women’s autonomy.

Pooling for the future

This paper has touched on the many shortfalls of WI research to date as well as foreseeable difficulties of future research surrounding WI for labour and birth. Future research requires greater emphasis on both the quantitative and qualitative aspects of water use for labour and birth to ensure that policies incorporate both the risk/benefit analysis as well as the opportunity for shared and informed decision-making.

This includes greater exploration of the experiences and perceptions of women and importantly, an examination of current WI policies to determine how they are informed and developed and to what extent they facilitate the practice and support women’s autonomy.

Not only is there the potential for this all-encompassing research to assist maternity care providers in working with autonomy as practitioners and ensuring their ability to advocate for women but there is also the potential for the use of water for labour and birth to have positive outcomes in a system that has an ever increasing rate of intervention and deviation from what can be both a normal and natural process.


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Position statement on the use of water for labour and birth 

In light of the publication of recent articles that report the growing demand from women around the world who want to have a natural, drug free, non-medicalised birth (Weiss 2014 and Gilbert 2015) we need to look at ways to help them have this experience.

If they are not going be reliant on analgesia for pain relief they need options to help them cope with the pain to allow a physiological labor to unfold.

Immersion in warm water has been unequivocally proven to be of great benefit both physiologically and psychologically.

It is not important if the baby is born in water.

In fact, water birth should be de-emphasised as it is a controversial issue in many parts of the world.

The key point and main benefit that needs to be made and focused on is how women who enter a warm pool of water in established labour with strong contractions find that they are able to cope with the pain and have a natural birth.

Women have a greater sense of fulfillment and accomplishment and babies experience a non-traumatic birth.

Aside from the obvious benefits to mothers and babies, midwives experience greater job satisfaction and hospitals save money and optimise resources from the reduced use of analgesia, medical intervention and shorter hospital stays.

Nearly a third of women benefited from the use of a water birth pool in the UK in 2014 (National Maternity Survey 2014).

With up to 60% of mothers open to natural birth now is the time for midwives, obstetricians and hospitals to consider making this safe, low cost option available.

Studies have shown that upright labour positions are associated with a reduced second stage, fewer episiotomies or instrumental intervention in contrast to mothers labouring on their backs. (Gupta, Hofmeyr and Shehmar 2012 and Gupta and Nikodem 2000).

Many women also feel empowered in an upright position, and experience a sense of control over their labour (Balaskas 2001).

On land women need to contend with the force of gravity that limits their ability to assume upright postures especially as labour progresses and they feel tired.

Many women do not have the fitness or stamina to maintain upright postures for lengths of time. (Gupta JK, Hofmeyr GJ, Smyth R 2007).

The transition from the land to water helps revive and energise the mother giving her a new lease on life and sense of purpose.

The buoyancy of water supports the mother reducing her relative weight by approx. 33% (Archimedes Principle) allowing her to easily explore the full range of beneficial upright positions in comfort and move in ways that were not possible on land.

The calming, relaxing effect of the warm water promotes the flow of oxytocin, a powerful hormone that plays a huge role in childbirth, causing the uterus to contract and triggering the ‘fetal ejection reflex’.

Michel Odent has expounded upon the beneficial physiological effect that immersion in water during labour has on hormone secretion, including observations that women entering warm water experience oxytocin surges which can advance dilation and stimulate contractions (Odent 2014).

The space, depth and design features of Active Birth Pools allow women to move freely to find and be supported in the upright positions that are most comfortable and beneficial for a physiological labor to unfold.



Management of High Risk Women using Birthing Pool and Telemetry

There is evidence that water emersion in labour offers women a safe and effective form of pain relief in labour to those women who meet the criteria (NICE, 2007; NICE, 2014; Garland, 2011).

The use of telemetry provides women greater choice and control over their birth experience to facilitate the use of water (Birthing Pool or Bath) in labour and birth where their pregnancy and labour has been categorised as high risk and requires continuous fetal monitoring.

The Standard Operating Procedure (SOP) has been written to facilitate continuous fetal monitoring of high risk women in labour and birth who wish to use the birthing pool / water.

Telemetry is a wireless fetal monitoring device which facilitates continuous toco graph (CTG) monitoring where clinically indicated in the first and second stage of labour on a consultant led delivery suite.

Prior to the woman being offered the use of the birthing pool on the Delivery Suite consideration should be given to the plan of care and requirements of the woman and baby having reviewed the fully ante natal history.

The following lists are not exhaustive and full clinical assessment should be made on admission to delivery suite.

Click here for a copy of these guidelines

There may never be a big enough trial of water birth – now what?

Randomised studies need to have enough people in them to be able to determine harm and efficacy (1). Further, the type of people who would typically receive the intervention, need to be recruited, so that the results will be generalizable. This latter point was a major criticism of the ARRIVE trial of induction of labour (6). Most women they approached did not want to be randomised and did not participate, which threatens the validity of the results (6). Over 40 years of waterbirth access in hospital settings, there has never been an adequate RCT of waterbirth to determine safety (7).

Is an RCT of waterbirth possible?

A new study was designed to answer this question (7). Low-risk participants were recruited to an observational study (where they could decide whether to have a waterbirth or landbirth). During recruitment participants were surveyed about whether they would agree to be randomised in a future trial. Midwives assessed eligibility for waterbirth throughout labour using a clinical guideline, and asked women to leave the bath if indicated.  Midwives assessed waterbirth intention at onset of second stage. The research analysed clinical outcomes in two ways.

The first analysis was intention-to-treat. For example, a woman who planned waterbirth but subsequently got out of the bath (for any reason), was analysed as a waterbirth. The second analysis was treatment received. For example, a woman who planned a waterbirth but got out of the bath in second stage due to meconium-stained liquor, would be analysed as a landbirth. However, if all women who get out of the bath for a clinical indication are analysed in the landbirth group, this makes landbirth appear to be causing poor outcomes. This is known as confounding. To avoid this problem, women who planned waterbirth but had a landbirth, were excluded from the second analysis (7).

Key findings

The study recruited 1260 women. Of those, 85% indicated they would not agree to be randomised in a trial of waterbirth. Therefore, modelling showed, 6,000 women would need to be invited to participate in an RCT for it to be large enough to test the safety of waterbirth (7).

Only 550 women remained low risk at onset of second stage, 351 intended waterbirth and 199 intended landbirth. Importantly, 48 women who got out of the bath for birth were excluded. For both analyses, waterbirth and landbirth had similar outcomes for low risk women.  There was no difference for neonatal outcomes, except for cord snap, which occurred four times in the waterbirth group and never in the landbirth group. This finding has been found in previous studies (8, 9). There were no neonatal deaths reported, however the study was not big enough to make conclusions about safety for such a rare outcome. Importantly, a recent observational study with over 17,000 waterbirths, which is big enough to determine safety, reported no increased risk in neonatal death (9).

The future of waterbirth

A randomised trial of waterbirth, big enough to solve the question of neonatal safety, is unlikely feasible.  The best available evidence says that for selected low-risk women, who remain low risk throughout labour and birth, well-managed waterbirth is a safe option with many benefits. Therefore, the lack of safety data from randomised trials should no longer be accepted as a barrier to waterbirth. Instead, results of this study should mark a distinct turning point in research to focus squarely on improving waterbirth practice. For example, cord snap may be more common in waterbirth. This could be due to baths that are too deep to accommodate babies with short cords coming to the surface. Research on this topic would be useful, alongside education that includes simulation drills of cord snap, and management of other maternity emergencies in the bath.

 Highlighted article

Allen, J., Gao, Y., Dahlen, H., et al. (2022). Is a randomized controlled trial of waterbirth possible? An Australian feasibility study. Birth, 00, 1– 12.

Blog written by

Dr Jyai Allen


  1. Masic, I., Miokovic, M., & Muhamedagic, B. (2008). Evidence based medicine – new approaches and challenges. Acta Informatica Medica,16(4), 219–225.
  2. Gilbert, R. (2002). Water birth—A near-drowning experience. Pediatrics, 110(2), 409.
  3. Wright, S., Abdel-Latif, M. E. (2016). Case report of neonatal near drowning associated with underwater birth. Case Reports in Perinatal Medicine, 5(2),139-140.
  4. American Academy of Pediatrics, American College of Obstetricians and Gynecologists. (2016). Immersion in Water during Labour and Delivery.  ACOG.
  5. Cluett, E.R.Burns, E.Cuthbert, AImmersion in water during labour and birth. (2018). Cochrane Database of Systematic Reviews, 5:CD000111
  6. Carmichael, S. L., & Snowden, J. M. (2019). The ARRIVE trial: Interpretation from an epidemiologic perspective. Journal of midwifery & women’s health, 64(5), 657–663.
  7. Allen, J., Gao, Y., Dahlen, H., et al. (2022). Is a randomized controlled trial of waterbirth possible? An Australian feasibility study. Birth, 00, 1– 12.
  8. Gilbert, R.E., & Tookey, P.A. (1999). Perinatal mortality and morbidity among babies delivered in water: surveillance study and postal survey. British Medical Journal, 319(7208), 483487.
  9. Bovbjerg, M.L.Cheyney, M.Caughey, A.B. (2021). Maternal and neonatal outcomes following waterbirth: a cohort study of 17 530 waterbirths and 17 530 propensity score-matched land births. British Journal of Obstetric and Gynaecology. Epub ahead of print.

Prospective cohort study of water immersion in an Irish maternity setting

Prospective cohort study of water immersion for labour and birth compared with standard care in an Irish maternity setting

Paula L BarryLean E McMahonRuth AM BanksAnn M Fergus, Deirdre J Murphy


Objective To examine the birth outcomes for women and babies following water immersion for labour only, or for labour and birth.

Design Prospective cohort study.

Setting Maternity hospital, Ireland, 2016–2019.

Participants A cohort of 190 low-risk women who used water immersion; 100 gave birth in water and 90 laboured only in water. A control group of 190 low-risk women who received standard care.

Methods Logistic regression analyses examined associations between water immersion and birth outcomes adjusting for confounders. A validated Childbirth Experience Questionnaire was completed.

Main outcome measures Perineal tears, obstetric anal sphincter injuries (OASI), postpartum haemorrhage (PPH), neonatal unit admissions (NNU), breastfeeding and birth experiences.

Results Compared with standard care, women who chose water immersion had no significant difference in perineal tears (71.4% vs 71.4%, adj OR 0.83; 95% CI 0.49 to 1.39) or in OASI (3.3% vs 3.8%, adj OR 0.91; 0.26–2.97). Women who chose water immersion were more likely to have a PPH ≥500 mL (10.5% vs 3.7%, adj OR 2.60; 95% CI 1.03 to 6.57), and to exclusively breastfeed at discharge (71.1% vs 45.8%, adj OR 2.59; 95% CI 1.66 to 4.05). There was no significant difference in NNU admissions (3.7% vs 3.2%, adj OR 1.06; 95% CI 0.33 to 3.42). Women who gave birth in water were no more likely than women who used water for labour only to require perineal suturing (64% vs 80.5%, adj OR 0.63; 95% CI 0.30 to 1.33), to experience OASI (3.0% vs 3.7%, adj OR 1.41; 95% CI 0.23 to 8.79) or PPH (8.0% vs 13.3%, adj OR 0.73; 95% CI 0.26 to 2.09). Women using water immersion reported more positive memories than women receiving standard care (p<0.01).

Conclusions Women choosing water immersion for labour or birth were no more likely to experience adverse birth outcomes than women receiving standard care and rated their birth experiences more highly.

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Waterbirth: a national retrospective cohort study… 2021

Waterbirth: a national retrospective cohort study of factors associated with its use among women in England

H. Aughey,J. Jardine,N. Moitt,K. Fearon,J. Hawdon,D. Pasupathy,I. Urganci,NMPA Project Team &T. Harris



Waterbirth is widely available in English maternity settings for women who are not at increased risk of complications during labour. Immersion in water during labour is associated with a number of maternal benefits. However for birth in water the situation is less clear, with conclusive evidence on safety lacking and little known about the characteristics of women who give birth in water.

This retrospective cohort study uses electronic data routinely collected in the course of maternity care in England in 2015–16 to describe the proportion of births recorded as having occurred in water, the characteristics of women who experienced waterbirth and the odds of key maternal and neonatal complications associated with giving birth in water.


Data were obtained from three population level electronic datasets linked together for the purposes of a national audit of maternity care. The study cohort included women who had no risk factors requiring them to give birth in an obstetric unit according to national guidelines. Multivariate logistic regression models were used to examine maternal (postpartum haemorrhage of 1500mls or more, obstetric anal sphincter injury (OASI)) and neonatal (Apgar score less than 7, neonatal unit admission) outcomes associated with waterbirth.


46,088 low and intermediate risk singleton term spontaneous vaginal births in 35 NHS Trusts in England were included in the analysis cohort. Of these 6264 (13.6%) were recorded as having occurred in water. Waterbirth was more likely in older women up to the age of 40 (adjusted odds ratio (adjOR) for age group 35–39 1.27, 95% confidence interval (1.15,1.41)) and less common in women under 25 (adjOR 18–24 0.76 (0.70, 0.82)), those of higher parity (parity ≥3 adjOR 0.56 (0.47,0.66)) or who were obese (BMI 30–34.9 adjOR 0.77 (0.70,0.85)). Waterbirth was also less likely in black (adjOR 0.42 (0.36, 0.51)) and Asian (adjOR 0.26 (0.23,0.30)) women and in those from areas of increased socioeconomic deprivation (most affluent versus least affluent areas adjOR 0.47 (0.43, 0.52)).

There was no association between delivery in water and low Apgar score (adjOR 0.95 (0.66,1.36)) or incidence of OASI (adjOR 1.00 (0.86,1.16)). There was an association between waterbirth and reduced incidence of postpartum haemorrhage (adjOR 0.68 (0.51,0.90)) and neonatal unit admission (adjOR 0.65 (0.53,0.78)).


In this large observational cohort study, there was no association between waterbirth and specific adverse outcomes for either the mother or the baby. There was evidence that white women from higher socioeconomic backgrounds were more likely to be recorded as giving birth in water. Maternity services should focus on ensuring equitable access to waterbirth.

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Labouring women who used a birthing pool in obsteric units in Italy: prospective observational study

Background: For women at low risk of childbirth complications, water immersion during labour is a care option in many high income countries.

Our aims were (a) to describe maternal characteristics, intrapartum events, interventions, maternal and neonatal outcomes for all women who used a birthing pool during labour who either had a waterbirth or left the pool and had a landbirth, and for the subgroup of women who had a waterbirth in 19 obstetric units, and (b) to compare maternal characteristics, intrapartum events, interventions, and maternal and neonatal outcomes for women who used a birthing pool with a control group of women who did not use a birthing pool for whom we prospectively collected data in a single centre.

Methods: Prospective observational study in 19 Italian obstetric units 2002-2005.

Participants were: (a) 2,505 women in labour using a birthing pool in 19 obstetric units; and (b) 114 women in labour using a birthing pool and 459 women who did not use a birthing pool in one obstetric unit.

Descriptive statistics were calculated for the sample as a whole and, separately, for those women who gave birth in water. Categorical data were compared using Chi square statistics and continuous data by T-tests.

Results: Overall, 95.6% of women using a birthing pool had a spontaneous vertex delivery, 63.9% of which occurred in water. Half of nulliparas and three quarters of multiparas delivered in water.

Adverse maternal and neonatal outcomes were rare.

There were two cases of umbilical cord snap with waterbirth.

Compared with controls, significantly more women who used a birthing pool adopted an upright birth position, had hands off delivery technique, and a physiological third stage.

Significantly fewer nulliparas had an episiotomy, and more had a second degree perineal tear, with no evidence of a difference for extensive perineal tears.

Conclusions: Birthing pool use was associated with spontaneous vaginal birth.

The increase in second degree tears was balanced by fewer episiotomies.

Undue umbilical cord traction should be avoided during waterbirth.

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Factors influencing water immersion during labour: qualitative case studies of six maternity units in the United Kingdom

Background: Water immersion during labour can provide benefits including reduced need for regional analgesia and a shorter labour.

However, in the United Kingdom a minority of women use a pool for labour or birth, with pool use particularly uncommon in obstetric-led settings.

Maternity unit culture has been identified as an important influence on pool use, but this and other possible factors have not been explored in-depth.

Therefore, the aim of this study was to identify factors influencing pool use through qualitative case studies of three obstetric units and three midwifery units in the UK.

Methods: Case study units with a range of waterbirth rates and representing geographically diverse locations were selected. Data collection methods comprised semi-structured interviews, collation of service documentation and public-facing information, and observations of the unit environment.

There were 111 interview participants, purposively sampled to include midwives, postnatal women, obstetricians, neonatologists, midwifery support workers and doulas.

A framework approach was used to analyse all case study data.

Results: Obstetric unit culture was a key factor restricting pool use.

We found substantial differences between obstetric and midwifery units in terms of equipment and resources, staff attitudes and confidence, senior staff support and women’s awareness of water immersion.

Generic factors influencing use of pools across all units included limited access to waterbirth training, sociodemographic differences in desire for pool use and issues using waterproof fetal monitoring equipment.

Conclusions: Case study findings provide new insights into the influence of maternity unit culture on waterbirth rates.

Access to pool use could be improved through midwives based in obstetric units having more experience of waterbirth, providing obstetricians and neonatologists with information on the practicalities of pool use and improving accessibility of antenatal information.

In terms of resources, recommendations include increasing pool provision, ensuring birth room allocation

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Midwives’ experience of their education, knowledge and practice around immersion in water for labour or birth

Background: There is limited research examining midwives’ education, knowledge and practice around immersion in water for labour or birth. Our aim was to address this gap in evidence and build knowledge around this important topic.

Methods: This mixed method study was performed in two phases, between August and December 2016, in the birth centre of a tertiary public maternity hospital in Western Australia.

Phase one utilised a cross sectional design to examine perceptions of education, knowledge and practice around immersion in water for labour or birth through a questionnaire.

Phase two employed a qualitative descriptive design and focus groups to explore what midwives enjoyed about caring for women who labour or birth in water and the challenges midwives experienced with waterbirth.

Frequency distributions were employed for quantitative data. Thematic analysis was undertaken to extract common themes from focus group transcripts.

Results: The majority (85%; 29 of 34) of midwives surveyed returned a questionnaire.

Results from phase one confirmed that following training, 93% (27 of 29) of midwives felt equipped to facilitate waterbirth and the mean waterbirths required to facilitate confidence was seven.

Midwives were confident caring for women in water during the first, second and third stage of labour and enjoyed facilitating water immersion for labour and birth.

Finally, responses to labour and birth scenarios indicated midwives were practicing according to state-wide clinical guidance.

Phase two included two focus groups of seven and five midwives.

Exploration of what midwives enjoyed about caring for women who used water immersion revealed three themes: instinctive birthing; woman-centred atmosphere; and undisturbed space.

Exploration of the challenges experienced with waterbirth revealed two themes: learning through reflection and facilities required to support waterbirth.

Conclusions: This research contributes to the growing knowledge base examining midwives’ education, knowledge and practice around immersion in water for labour or birth.

It also highlights the importance of exploring what immersion in water for labour and birth offers midwives, as this research suggests they are integral to sustaining waterbirth as an option for low risk women.

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