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Monday’s medical myth: water births are risky

“Women aren’t dolphins” is a phrase often bandied about by those who question why women want to immerse themselves in pools or warm baths during labour and birth. They forget that we’re not mountain goats…

Women can move more easily in water, enabling them to change position with ease. Flickr/kTLindSAy

“Women aren’t dolphins” is a phrase often bandied about by those who question why women want to immerse themselves in pools or warm baths during labour and birth. They forget that we’re not mountain goats or birds, but that doesn’t stop us from rock climbing or hang gliding.

As more scientific evidence emerges about the benefits of water immersion in labour and birth, hospitals and birth centres are increasingly adding large baths to their delivery rooms. The New South Wales department of health has even given a directive that “all maternity services offer access to water immersion in labour (target 100% by 2015)”, in an attempt to stem the rising caesarean section rate.

There are tales of generations of women in the South Pacific giving birth in shallow sea water, but long before this – and possibly throughout the history of humankind – water has been used for pain relief.

The modern use of water immersion for labour and birth began in 1970s Russia when Igor Tjarkovsky, a boat builder, began looking into the therapeutic effects of water. He later installed a glass tank in his home for women to use during childbirth.

Michel Odent, the French obstetrician, went on to popularise water immersion in the 1970s and 80s in Europe, after installing a plastic paddling pool in a French hospital and finding it reduced women’s need for painkillers. His first water birth occurred by accident and Odent soon realised the potential benefits of leaving women in the water for the birth.

Water births moved from fad to mainstream maternity care in 1993, with the publication of the United Kingdom’s Changing Childbirth report, which recommended pool facilities be an option available to women in all UK maternity units.

Hospitals and birth centres are increasingly installing large baths in birthing suites. AmySelleck

The benefits of using water in labour are mainly attributed to buoyancy, hydrostatic pressure and the effect of warmth. Women can move more easily than on land, enabling them to change position with ease. Movement and relaxation help facilitate positive neuro-hormonal interactions that alleviate pain naturally.

There is some evidence that water immersion may be associated with improved blood flow in the uterus, lower blood pressure, less painful contractions, shorter labours and fewer interventions. There are also psychological benefits, with women feeling more in control and that they have their own space, with the bath forming a natural barrier between her and the health providers.

A common concern with water birth is that the baby could try to breathe underwater and drown. But healthy babies have what’s called a diving reflex (or bradycardic response), which causes the infant to hold his breath when under water. The reflex is stimulated via the the infant’s facial skin receptors, which detect the water and inhibits breathing.

There are also concerns about increased tearing of the perineum (the tissue between the vagina and anus) due to the lack of control of the baby’s advancing head. But randomised trials to date, and more importantly a systematic review of these trials, has not shown this to be the case.

Last month I published a study in the Journal of Midwifery examining the outcomes of 6,144 Australian women who had normal vaginal births in a birth centre over a 12 year period. I compared outcomes for the mother and baby when women gave birth in water, with those who gave birth in six other birth positions on land: kneeling or all fours, squatting, side lying, semi seated, using a birth stool and standing.

There’s no evidence to show water births increase risks for babies. MuddyBootsPhoto

Compared with water birth, the women who gave birth on a birth stool had nearly one-and-a- half times higher rate of major perineal trauma and more than twice the rate of haemorrhage after delivery.

There was no difference in major perineal trauma and haemorrhage after delivery between women who gave birth in water and those who opted for a semi-seated position, the most common birth position in Australia.

Compared with water birth however, babies born in a semi-seated position had a four-and-a-half times higher incidence of five-minute APGAR scores less than seven. APGAR scores rate the newborn’s breathing effort, heart rate, muscle tone, reflexes and skin colour. A score of less than seven at five minutes following the birth indicates medical intervention was needed to resuscitate the baby.

We controlled for as many variables as we could, including whether it was a first or subsequent birth, a long period of pushing, a big baby, or a midwife or obstetrician undertaking the delivery. All these women had normal vaginal births so surgical birth was not a variable.

So the idea that babies are more likely to drown if born in water, or that rates of tearing and injury are worse, doesn’t hold up.

While women may not be dolphins, they are drawn to water during labour and birth, with little evidence of harm and some evidence of benefit. And once experienced, women usually make the same choice for a subsequent birth and report many benefits to this style of birth.

Join the conversation

13 Comments sorted by

  1. Michael Tam

    logged in via Twitter

    Thanks for an interesting article Hannah!

    It should be noted, however, that although we wouldn't expect "healthy" newborns to aspirate, it may be an issue for a neonate in distress (and to be nit-picky, the article you linked to by Goksör and colleagues only had babies older than 2 months). In such babies, water birth may be associated with greater morbidity than air birth: http://dx.doi.org/10.1111/j.1440-1754.2011.02241.x

    However, I agree that these appear to be (very) small overall risks.

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  2. Sue Ieraci

    Public hospital clinician

    If there is any myth to be busted here, it is that "a water birth is a water birth".

    Unfortunately the author has not outlined the specific situations in which having the mother sitting in a tub of water might NOT be safe.

    Certainly warm water can have a soothing effect - for those who wish to avoid the more effective pharmacological methods. The buoyancy effect, however, is rarely achieved the way "water birth" is practised in Australia, as the mother is not deeply immersed.

    It would be…

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  3. Amy Tuteur

    logged in via Facebook

    A simple question for waterbirth advocates like Hannah Dahlen::

    Would you completely immerse your head (eyes open, of course) in the fecally contaminated bloody water of a birth pool in the aftermath of a birth?

    I have a second question:

    If you wouldn’t for a moment contemplate immersing your head in a pool of water with feces floating in it, why do you think it is a good idea to force your baby to do so?

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    1. Account Deleted

      logged in via email @drdrb.net

      In reply to Amy Tuteur

      Q1) No, I'm not a newborn.
      Q2) So it can get the necessary gut bacteria to colonise the colon and help its digestion of milk.

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    2. Sue Ieraci

      Public hospital clinician

      In reply to Account Deleted

      James Haughton - where did you get the idea that the newborn needs to immerse its head in a pool of contaminated water to get gut bacteria?

      As you may know, birth generally occurs through the vagina, not the bowel. You may want to read up of the natural vaginal vs gut flora, and also on the resultant health outcomes for different types of birth.

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  4. Laurie Willberg

    Journalist

    "[Water birthing: retrospective review of 2625 water births. Contamination of birth pool water and risk of microbial cross-infection].

    [Article in Italian]

    Thöni A, Mussner K, Ploner F.

    Source

    Reparto di Ginecologia e Ostetricia, Ospedale di Vipiteno, Bolzano, Italy. albin.thoeni@as-bressanone.it

    Abstract

    The aim of this study was to document the practice of 2625 water births at Vipiteno over the period 1997-2009 and compare outcome and safety with normal vaginal delivery…

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    1. Account Deleted

      logged in via email @drdrb.net

      In reply to Laurie Willberg

      Your last sentence directly contradicts the previous sentence quoted from the article.
      Furthermore, babies are supposed to be exposed to the mother's fecal matter so they can get the gut bacteria they need, which is one reason why c-section babies get sick more frequently - they don't get the bacterial exposure from the mother: http://journals.lww.com/jpgn/Fulltext/1999/01000/Fecal_Microflora_in_Healthy_Infants_Born_by.7.aspx

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    2. Laurie Willberg

      Journalist

      In reply to Laurie Willberg

      Sorry for the awkward sentence structure.
      You bring up a fascinating aspect of early gut colonization most people are unaware of -- thank you!
      I'm rather mortified that expectant mothers are being given antibiotics prior to delivery considering the damage that they do to healthy gut flora. Is this not also a likely the reason for c-section babies getting sick more frequently? The antibiotics would also contaminate the mother's breast milk, not to mention damaging the gut flora of the mother.

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    3. Sue Ieraci

      Public hospital clinician

      In reply to Laurie Willberg

      The reason women are given antibiotics prior to delivery is that it significantly reduces the risk of sepsis (life-threatening infection) in the newborn going through the birth canal that is colonised with Group B strep.

      A useful article was published on this site a few months ago with the facts about neonatal gut flora:
      The author stated: "Although birth is when we first encounter microbes, the process of acquiring a stable gut microbiota takes time. As any parent knows, an infant’s poo will…

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  5. Julie Leslie

    GIS Coordinator

    That is one lovely bath in the picture included on this article. But does anyone else think it is not particularly accessible? Most pregnant women are not exactly graceful at their late stages, let alone during labour. It looks like once you are in, you are staying in.

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  6. Suzy Gneist
    Suzy Gneist is a Friend of The Conversation.

    Multi-tasker at Graphic Design & Montville Coffee

    Safer or not, I found water birth a less traumatic and exhausting experience than normal delivery (having experienced both) for myself and the baby.
    Major tearing, stitches, followed by a nasty AB-resistant infection only occurred during the 'land' birth in a public hospital.
    The submersion in warm water between contractions was relaxing and comfortable (in comparison to staying semi- or upright) and gave me time to recover strength and therefore shorten the overall labour and recovery time…

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    1. Sue Ieraci

      Public hospital clinician

      In reply to Suzy Gneist

      Ms Gneist - are you aware that first births are much more likely to be long and difficult?

      Many women have long, painful first labours, then choose a different setting, and assume that the improvement was due to the changed setting, when it was just an easier labour and delivery.

      You say "Out of the two, my water experience seemed safer and healthier for both of us." I would say - you had the same experience as most (not all) women - your second delivery was easier than your first.

      It's important to avoid making conclusions about your two personal experiences when the data reported by researchers reflects thousands of deliveries.

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    2. Suzy Gneist
      Suzy Gneist is a Friend of The Conversation.

      Multi-tasker at Graphic Design & Montville Coffee

      In reply to Suzy Gneist

      @Ms Ieraci - I speak from my experience not from your favoured unreferenced research averages - I am an individual and as such do not fit most of these averages.
      Neither of my deliveries were difficult apart for the unrequested/unwanted interventions of some staff before, during and after the first. Since you do not know the actual circumstances of my hospital experience, and I am not going to bare them here, I can assure you the discomfort of my experience had very little to do with the length of delivery - it had a lot to do with how it was handled and the consequences, all of which led me to avoid another repeat of such an experience at all costs.
      Please show me the data you are referring to that shows the danger of water over hospital birth for healthy (low/normal risk) mothers - as in other threads here, you seem to belittle other people's experience (even if presented as personal) while quoting your own as superior knowledge, frequently without referencing them.

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