PRO

I believe water birth is a reasonable choice for women expecting an uncomplicated vaginal birth and healthy newborn. My position is informed by decades of water birth research and clinical expertise, and grounded in respect women's autonomy to make informed decisions for labor pain relief.

Twelve randomized controlled trials (RCTs) confirm that labor in water safely decreases pain medication use and duration of first-stage labor (Cluett & Burns, 2012). Water birth data are limited in comparison; 2 RCTs and 36 observational studies describe more than 31,000 cases (Nutter, Meyer, Shaw-Battista, & Marowitz, 2014). Limited RCT data are cited as reason to restrict water birth to research settings, with assertions that benefits are unproven and isolated case reports demonstrate neonatal harms. However, published cohort and case-control studies provide higher quality evidence than anecdotes or the recent cautionary committee opinion from the American Academy of Pediatrics and American College of Obstetricians and Gynecologists (Nutter, Meyer, et al.). The American College of Nurse-Midwives, American Association of Birth Centers, and United Kingdom's Royal Colleges of Obstetricians and Midwives support water birth for healthy, well-informed women with experienced attendants (Nutter, Meyer, et al.).

Mothers know that water birth is an international option and reject blanket restrictions with excellent questions such as: (1) How can healthcare providers interpret water birth data so differently?; (2) Do analgesia and anesthesia have rare but severe adverse neonatal effects?; (3) Do labor pain medications have neonatal benefits?; (4) Why are maternal water birth benefits questioned when I'm telling you I feel less pain in water and I don't want to get out?; and (5) If water birth is prohibited in hospitals without research protocols won't there be more home water births?

Women seek the option of water birth because they understand that judicious rather than routine use pain medication promotes optimal outcomes. Women may view water birth availability as a litmus test for providers' willingness to individualize care and support natural childbirth. When we dismiss and subjugate water birth desires to rare and unknown neonatal risk, we fail to recognize a rational evidence-based pain relief choice that decreases pharmacological intervention and accompanying side effects and risks.

It is imperative that healthcare providers give women the best available data on labor pain relief options and counter misinformation, including the myth that there is no evidence of water birth safety. Although limited, peer-reviewed water birth research provides assurance that any associated risks are rare when standard screening and management practices are employed (Nutter, Meyer, et al., 2014). Studies demonstrate comparable outcomes for water births and conventional births including perinatal mortality, nursery admissions, and other aggregate neonatal health measures (Nutter, Meyer, et al.). Water birth research confirms women's reports of pain relief and suggests possible additional benefits including less severe perineal laceration and episiotomy (Nutter, Meyer, et al.).

Robust comparative analyses of labor pain relief options are lacking, due to limited data and frequent failure to include appropriate control groups, such as women who desire natural childbirth. Informed consent for labor pain relief must include this uncertainty and incorporate women's preferences. Transparency is key to ethical maternity care, which requires that women understand all labor pain relief options, including efficacy and other benefits, risks, alternatives, and the quality of available evidence. Some women will continue to choose water birth after these informed consent discussions. Provider familiarity with study protocols and practice guidelines (Nutter, Shaw-Battista, & Marowitz, 2014) should minimize risk and optimize water birth outcomes, while the practice is further studied among pain relief options for safe and satisfying childbirth.

References

Cluett E. R., Burns E. (2012). Immersion in water in labour and birth. The Cochrane Database of Systematic Reviews, (2), CD000111. [Context Link]

Nutter E., Meyer S., Shaw-Battista J., Marowitz A. (2014). Waterbirth: An integrative analysis of peer-reviewed literature. Journal of Midwifery & Women's Health, 59(3), 286-319. doi:10.1111/jmwh.12194 [Context Link]

Nutter E., Shaw-Battista J., Marowitz A. (2014). Waterbirth fundamentals for clinicians. Journal of Midwifery & Women's Health, 59(3), 350-354. doi:10.1111/jmwh.12193 [Context Link]

CON

As perinatal nurses it is our duty to care and protect women and infants during childbirth. First and foremost we must do no harm. Although the risk is slight, infants born underwater are at greater risk compared to infants not born underwater. Rare fetal conditions such as short umbilical cord can lead to cord rupture and infant hemorrhage. Uncommon maternal-fetal conditions such as shoulder dystocia and uterine inversion cannot be predicted and pose catastrophic threats. Some infants born underwater may experience traumatic injury or adverse clinical conditions such as aspiration pneumonia, sepsis, or hypoxic ischemic brain injury (American Academy of Pediatrics [AAP] & American College of Obstetricians and Gynecologists [ACOG], 2014).

As a human species, human birth has been land exclusive. To date, a number of retrospective reviews and two RCTs have been published about water birth. Other publications include testimonials and recommendations based on personal opinions.

Professional organizations such as AAP and ACOG (2014) have published reports stating the safety and efficacy of immersion in water during the second stage of labor hasn't been established, nor associated with maternal/fetal benefit. Rare case reports place newborns at risk; therefore, underwater birth should be considered experimental and should only occur in the context of appropriately designed clinical trials with informed consent (AAP & ACOG). Imagine a woman in hands and knees submerged in water while the provider is attempting to deliver the fetal posterior arm and release the impacted anterior shoulder. Emergency drills are challenging for perinatal departments to execute on a regular basis, much less conduct underwater; however, to ensure safety and reliability, underwater drills should be considered in units that use hydrotherapy during labor. Perhaps diminished pain perception during underwater birth minimizes stress and reduces stress hormone secretion. Theoretically, this may foster a gentler fetal transition to an ex-utero environment, but this is yet to be proven.

Let us look at the available evidence and how we can use what is known to care for women in labor. There is evidence suggesting hydrotherapy is safe and beneficial during labor, but how many perinatal nurses actually encourage and support women into the tub or shower on a routine basis?

Convincing evidence is needed to propose that birth under water is as safe and beneficial for the fetus as land birth. Data from well-designed RCTs are needed that answer questions such as what knowledge and understanding should childbearing woman have regarding underwater birth, who are appropriate candidates for underwater birth, what are the risks to the mother, what are the risks to the baby, what type of informed risk should be discussed and how should it be documented? Establishing proven infection control methods for cleaning soiled tubs, determining ideal length time of and temperature for water immersion during second stage, influence of underwater birth on respiratory effort of the emerging fetus, and when should the water be rapidly drained during an emergency verses using the buoyancy of water to facilitate manually lifting the woman out of the tub (Young & Kruske, 2013) are a just few questions nurse scientists should determine before moving forward with offering water birth.

Is there convincing evidence that birth underwater is safe, beneficial, and should be routinely offered? In my opinion, not yet. But, we could improve our efforts to offer alternatives to laboring in bed. Perinatal nurses can and should safely assist women into water during the first stage of labor. During hydrotherapy nurses cannot safely assess a woman and fetus from the nursing station via a central monitor. One-to-one nursing care at the bedside to provide continuous support, observation, and ongoing evaluation is essential. A policy about hydrotherapy during first-stage labor should be agreed upon by all key stakeholders and direct care providers. In second stage labor, nurses should provide high-quality, evidence-based care on land. Women should be assisted out of the water before birth is imminent.

References

American Academy of Pediatrics, & American College of Obstetricians and Gynecologists. (2014). Immersion in water during labor and delivery. Pediatrics, 133(4), 758-761. doi:10.1542/peds.2013-3794 [Context Link]

Young K., Kruske S. (2013). How valid are the common concerns raised against water birth? A focused review of the literature. Women and Birth, 26(2), 105-109. doi:10.1016/j.wombi.2012.10.006 [Context Link]