Labor in water may be safe, but not water delivery, according to ACOG

The American College of Obstetricians and Gynecologists and the American Academy of Pediatrics have issued a joint statement on water births, the first for the increasingly popular practice.

Proposed benefits for immersion during labor and delivery include a decrease in perinatal pain on account of increased venous return, a heightened sense of well-being and control, and a decreased level of perineal trauma. A 2009 Cochrane Review of 12 different trials showed a significant reduction in the use of epidural, spinal, paracervical analgesia, and anaesthesia rates among women who underwent water immersion when compared to controls (478/1254 vs 529/1245; risk ratio (RR) 0.90; 95% confidence interval (CI) 0.82 to 0.99, 6 trials).

Women who underwent water immersion also spent less time in the first state of labor (mean difference -32.4 minutes; 95% CI -58.7 to -6.13). However, no difference was found in assisted vaginal deliveries (RR 0.86; 95% CI 0.71 to 1.05, 7 trials), caesarean deliveries (RR 1.21; 95% CI 0.87 to 1.68, 8 trials), use of oxytocin infusion (RR 0.64; 95% CI 0.32 to 1.28, 5 trials), perineal trauma, or maternal infection. None of the studies in the review reported any benefit to the neonate.

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Potential complications include higher risk of infections for both mother and neonate due to ruptured membranes, difficulties in neonatal thermoregulation, umbilical cord avulsion, umbilical cord rupture, and the aspiration of water during birth. While complications from water labor and delivery are difficult to assess because denominators are not uniformly reported, a study included in the statement found 4 cases of severe respiratory distress in neonates after a water birth; one of the neonates eventually died of overwhelming sepsis from Pseudomonas aeruginosa.

Studies have also found that the “diving reflex,” which would prevent the aspiration of water during a water birth, is overridden in compromised neonates. A randomized control trial in the British Medical Journal found that 12% of the neonates delivered via water birth required admission to the neonatal intensive care unit (NICU); no neonate required admission to the NICU among those who were delivered without immersion.

The report concludes that immersion therapy for the first stage of labor may provide some pain relief and decreased duration of labor. However, no benefits for mother or neonate have been shown during the second stage of labor, and serious adverse effects have been found.

The report states that facilities that offer tubs and immersion pools for the first stage of labor should have rigorous protocols for candidate selection; infection control procedures; the ability to monitor both mother and fetus while immersed; and protocols for moving women from the tubs if an emergent issue arises.

American College of Obstetricians and Gynecologists. Immersion in water during labor and delivery. 2014. http://www.acog.org/Resources_And_Publications/Committee_Opinions/Committee_on_Obstetric_Practice/Immersion_in_Water_During_Labor_and_Delivery. Accessed March 24, 2014.