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Water immersion during labour and birth has been around for several decades and continues to gain popularity today. There is growing evidence demonstrating the benefits of water immersion for women and birthing people and the safety for babies when compared to ‘land’ births. In the literature, water immersion may only refer to being in water for the labour only, whereas waterbirth refers to actually giving birth in water. So, are there any benefits or is it just a ‘nice’ thing to do? Are there any risks to birthing in water? Read on to find the answers!

The benefits

There have now been several studies into the safety of waterbirth, including randomised controlled trials (RCTs) which are considered the ‘gold standard’ in research. A 2018 Cochrane review (a review of available RCTs) on waterbirth, found that for low-risk women, with uncomplicated pregnancies, immersion in water in the first stage of labour probably reduces the need for regional analgesia (epidural or spinal). With regards to the second stage of labour, the evidence reviewed did not determine any difference, when comparing waterbirth to land birth, in the following outcomes: spontaneous vaginal birth, instrumental birth, caesarean section or neonatal unit admissions. The rate of third- and fourth-degree tears, estimated blood loss or third stage outcomes were unfortunately not reported on in the included trials. This review also concluded that there was no evidence to demonstrate any adverse effects on either the unborn baby, the newborn baby, or the woman from labouring of giving birth in water.

A 2015 integrative review of peer reviewed research (this means research not limited to RCTs), highlighted several benefits of water immersion and waterbirth. Nutter et al. (2015) found that waterbirth increases maternal satisfaction with pain relief and the birth experience, decreased the chance of perineal trauma, including episiotomy and severe perineal tears and may decrease the likelihood of postpartum haemorrhage. For newborns, they found that there were no differences in neonatal mortality (death) rates, neonatal infection rates or admissions to a neonatal nursery, between waterbirths and uncomplicated land births.

The great people over at Evidence Based Birth have done a thorough review of the literature on waterbirth and from that summarised the following potential benefits of waterbirth for women and birthing people:

• Higher rates of spontaneous vaginal birth
• Lower rates of have oxytocin augmentation
• Lower rates of episiotomy (cut to the vagina)
• Higher rates of intact perineum (particularly in high episiotomy settings)
• Less pain and greater satisfaction with the birth experience
• Less medication needed for pain relief
• Possible lower rates of postpartum haemorrhage (heavy bleeding after birth)
• Possible lower rates of severe perineal trauma (third- and fourth-degree tears – particularly in high episiotomy settings)

‘Low risk’ vs. ‘high risk’

It’s important to note that most of the literature refers to women with healthy, uncomplicated pregnancies, those labelled ‘low risk’ women. There is a glaringly obvious lack of research into water immersion and waterbirth for ‘high risk’ women, some of whom undoubtedly would benefit from using water for labour and/or birth in the same way that their ‘low risk’ counterparts do. Hospitals frequently have policies stating that women and birthing people with a BMI over a certain amount (often 35 or 40) are either not ‘allowed’ to use a birthing pool or require a meeting with a consultant midwife or obstetrician to plan a birth ‘out of guidelines’. One of the worries here is that in the unlikely event of a maternal collapse, it may be difficult to get someone out of the pool who has a higher BMI. Most hospitals have hoists for this purpose and the counterargument to this, is that anyone who has collapsed and is unconscious would be difficult to extract from a birth pool. On the topic of BMI, Sara Wickham has recently written a book called ‘Plus Size Pregnancy’, which I would highly recommend all midwives, doulas and indeed pregnant women and people read. The book contains a section specifically on using a birth pool or a bath for labour and questions and dispels many myths associated with care provided to those with a high BMI during pregnancy. Another issue that prevents women and birthing people using the pool is where they have been advised to have continuous electronic fetal monitoring (CEFM). There are forms of wireless, waterproof CEFM that can be used in birthing pools and these need to be utilised far more frequently. Some NHS labour wards do have birthing pools, which is a step in the right direction, but whether ‘higher risk’ women and birthing people are being encouraged to use them is another question.

The risks

Those opposed to waterbirth will cite many very scary sounding risks. Birth is never without risk; this is something that is not very well accepted by mainstream maternity and obstetric care. As mentioned earlier, both the Cochrane review and the Nutter et al. (2015) review did not demonstrate any increased risk to women or babies with waterbirth.

Evidence Based Birth summarised the risks from their mega literature review as follows:

• In low episiotomy settings (midwife-led units, home) there may be a higher chance of mild labial tears
• Snapping of the baby’s umbilical cord is a rare, but possible occurrence
• Aspiration of water (where the baby breathes water into their lungs) has been reported, however not in prospective research since 1999, and most babies made a full recovery
• There have been individual case studies reporting newborn infection (however large research studies do not demonstrate an increase in infection)

Birth pool options

Most midwife-led birth centres, whether directly attached to a hospital or freestanding, will have birth pools and some labour wards have or are installing pools too. These pools are generally big, with hard walls and taps (think like a huge bath or jacuzzi – but without the jets!). Some of them have lights in them, so you can change the ambience. At home births, a large, soft-walled, inflatable birth pool is used – we like these ones, but there are many on the market! A long hose is used to fill up birth pools at home. These pools are available to buy or hire. Sometimes local independent midwives or doulas will rent them out too, and then all you need to buy is a fresh liner, hose and all the attachments. The only way to guarantee access to a pool during your labour and birth is to plan a homebirth. This is not saying everyone should plan a homebirth, rather giving a realistic picture of NHS maternity services. If you’re lucky, when you go into labour and you want to use a birth pool, the midwife-led unit will be open, and the pools will be free and available for you to use. It is worth noting however that in our experience staffing issues can cause midwife-led units to close, or the pools may be in use by someone else. Additionally, most (but not all) labour wards we have worked on do not have birth pools. Think about this when you’re writing your birth plan – have a plan B for if a pool is not available to you. Read more about birth plans here.

Have you considered using water for your labour and/or birth?

Overall, the research so far shows that using water for labour and birth is beneficial to women and birthing people, whilst also being safe for them and their babies. More research is emerging all the time, so I’m sure as time goes on more benefits to waterbirth will be revealed. We love witnessing waterbirths – anecdotally in our experience women and birthing people report finding the water incredibly soothing and it seems like a very gentle way for a baby to be born – into a warm, wet, dimly lit environment – just like in the womb! Water provides a sense of weightlessness and allow women and birthing people to adopt many different positions naturally and instinctively. All this intuitive movement is beneficial & supportive of the baby making their journey through the pelvis.

If you think you would like to use water for your labour and birth and are planning to birth in a hospital or a birth centre, but already know that this is not recommended for you for whatever reason, it can be worth either getting a second opinion from an independent midwife or seeking an appointment with your local NHS trusts consultant midwife (if they have one!) to make an ‘out of guidelines’ care plan. This may help you to create an individualised birth plan.

If you want to guarantee access to a birth pool for your labour and birth, get in touch to discuss the option of having a home birth with us. We can’t wait to hear from you!