ICEA Position Paper

Water Labor & Water Birth

Position and Dr. Grantly Dick-Read introduced it officially in
Russia, France, England and the US respectively (Avery,
It is well established in the research that 2013; Sprague, 2011). Odent published his results of the
maternal relaxation during labor may reduce first hundred waterbirths in the Lancet in 1983. His
findings were that anxiety and pain trigger a stress
the perception of pain, shorten the phases of response that leads to a reduction in uterine activity.
labor and may reduce the need for medical Laboring in water could overcome this stress response
interventions such as analgesia and by aiding relaxation, increasing endorphin release and
reducing the perception of pain (Mollamahmutoglu,
anesthesia. The International Childbirth
2012).
Education Association (ICEA) believes that for
those women whose pregnancies are low-risk
and where water immersion is not Review of the Literature
contraindicated, water labor and water birth Hydrotherapy expert Michel Odent outlined his research
may provide an environment for a gentle, at the maternity unit at Pithiviers, recording a definite
physiologic birth. change in labor contractions after immersion –
sometimes before immersion. This lead Odent and his
staff to believe that hydrotherapy not only actually
Background worked, but the anticipatory feelings of pain relief may
also release endorphins (Sprague, 2011). This may be
In nearly every culture, water signifies peace, calm and the cause of the prominent benefit of birth satisfaction
relaxation. From ancient times to the present, humans seen with waterbirths (Avery, 2013).
have used a warm bath to ease tension, quiet aching
muscles and relieve pain. The therapeutic use of water, Women who utilize hydrotherapy for labor and birth
also called hydrotherapy, during labor and birth is also should be deeply immersed in the water to cover the
not new. Historically, Japanese women made use of belly and up to the breast. “Full immersion”
warm labor pools to reduce labor pains and British promotes optimum physiologic responses, primarily
midwives use warm water as a source of pain relief. the stimulation of oxytocin and vasopressin (Avery,
France was the site of the first recorded waterbirth in 2013; Sprague, 2011). Entering the pool between
1805, however several individuals such as Igor 3-5 cm cervical dilation and staying approximately 2
Charkovsky, Dr. Michel Odent, Dr. Michael Rosenthal, hours (120 minutes) allows for optimum relaxation and

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labor progression. Some women who step out of the Benefits of Water Labor/Birth:
pool for 30 minutes and return, often experience
enhanced dilation. Recommended temperature for the Fetal
birth pool water is between 98° F and 101° F. Some Promotes positive maternal/infant bonding behaviors
resources recommend 95° F – 97.5 °F in order to such as skin-to-skin contact (Sprague, 2011).
maintain an optimal core temperature for mother and
baby. A baby with hyperthermia may show signs of Safety of Water Birth: Baby
distress (Avery, 2013; Sprague, 2011).
Apgar Scores
Authors of several studies have stated that there was no
Benefits of Water Labor/Birth: evidence of increased adverse effects with water
labor/water birth for the newborn. There were no
Maternal differences in NICU admissions or Apgar Scores (Avery,
Several studies have found significant benefits of 2013; Cluett, 2009; Dahlen, 2013; Nutter, 2014;
water labor/birth for mothers. These benefits include: Mollamahmutoglu, 2012).
 
Increased satisfaction with the birth (Sprague, 2011);
 Breathing/Drowning
Reduction in the perceptionof pain
 (Mollamahmutoglu, 2012); There are several factors that inhibit the baby from
 inhaling water during the birthing process. Barbara
 Increased endorphin release and increased
(Mollamahmutoglu, 2012; Sprague,
 relaxation
Harper, Director of Waterbirth International, explains
 the factors in this way:
 2011);
 “Approximately 24 to 48 hours before the onset of
Reduction in the need for pharmacologic pain relief
(Cluett,2009; Mollamahmutoglu, 2012; Sprague, spontaneous labor, the fetus experiences a notable
2011); increase in the prostaglandin E2 levels from the
placenta, which causes a slowing down or stopping of

More ease for assuming various labor/birth positions the fetal breathing movements (FBM). With the work of
(due to buoyancy) that leads to increased functional the musculature of the diaphragm and intercostal
diameter of the true pelvis (Avery,
2013; Dahlen, muscles suspended, there is more blood flow to vital
 2013; Mollamahmutoglu, 2012);
organs, including the brain. You can see the decrease in
 FBM on a biophysical profile, as you normally see the
Shorter first and second stage of labor due to a
reduction in stress hormones and catecholamines, fetus moving these muscles about 40% of the time.
which inhibit oxytocin and labor progress (Cluett,
 When the baby is born and the prostaglandin level is
 2009; Cortes, 2011; Mollamahmutoglu, 2012); still high, the baby’s muscles for breathing simply don’t
 work, thus engaging the first inhibitory response. A
Less perineal
 trauma (Dahlen, 2013; Henderson, second inhibitory response is the fact that babies are
2014);
  born experiencing acute hypoxia or lack of oxygen. It is a
Less postpartum hemorrhage (Dahlen, 2013). built in response to the birth process. Hypoxia causes
apnea and swallowing, not breathing or gasping. If the
fetus were experiencing severe and prolonged lack of
oxygen, it may then gasp as soon as it was born, possibly
inhaling water into the lungs. If the baby were in trouble
during the labor, there would be wide variabilities noted
in the fetal heart rate, usually resulting in prolonged

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bradycardia, which would cause the practitioner to ask less often at water-births; (5) kangaroo care at birth
the mother to leave the bath prior to the baby’s birth. promotes healthy newborns; (6) GBS and antibiotic-
The reduced temperature differential is another factor resistant GBS are more prevalent in hospital
thought by many to inhibit the newborn from initiating environments, where waterbirths are not an option; (7)
the breathing response while in water. Finally, the reflex a higher rate of underreporting of adverse events at
to begin breathing is only initiated after innervations of waterbirths compared to dry births; and/or (8) a
the trigeminal nerves in the face, nose and mouth are massively successful international campaign has covered
stimulated with a combination of room air and up the reporting of all deaths and disease from GBS
complete removal from the water. Once activated, the after waterbirths. GBS is not a contraindication to
pulmonary circulation begins for the first time with waterbirth (Avery, 2013; Cohain, 2010).
oxygen rich blood flowing into the lungs and carbon
dioxide removed” (Harper, 2012).
Contraindications for Waterbirth
Cord Avulsion The research shows that contraindications for waterbirth
Cord avulsion or snapping of the umbilical cord is a rare include mothers desiring a VBAC (vaginal birth after a
cesarean), Pitocin augmentation/induction or where
phenomenon but may occur during a waterbirth. During
telemetric EFM is not available. Maternity units may
a waterbirth, there may be a strong instinct to bring the
elect to add to the list of contraindications the use of
baby above the level of the water immediately after the
analgesia or anesthesia, multi-fetal gestation, and
birth. This may cause rapid cord traction with a higher
gestational age less than 37 weeks (Avery, 2013;
tension than a land birth. Risk factors for cord avulsion in
Harding, 2012).
both land births and water births include cord
abnormalities such as abnormal insertion of the cord
into the placenta, limited length of the cord, tumors or
hematomas. Cues that a cord avulsion has occurred Implications for Practice
include a sudden change in the color of the water to
According to Avery, warm water stimulates large, high-
deep red (due to a gush of blood), sudden release of velocity afferent nerve fibers, blocking smaller, slower
cord tension, visual confirmation of a detached cord, pain fiber impulses, thus reducing the amount of
snapping sound as newborn is lifted from the water, and painful stimuli reaching the reticular activating system
signs of neonatal hemorrhagic shock. With increased in the cerebral cortex (The Gate Control Theory).
professional and parent education, the incidence of cord Coupled with the hydrostatic pressure decreasing
avulsion can be greatly reduced (Schafer, 2014). muscular tension and the buoyancy of the water
enabling mothers to assume optimal positions, water
Reduced Group B Strep labor and birth are highly beneficial with the least
amount of risks to either mother or baby (Avery, 2013).
The literature demonstrates a GBS rate of 1 in 4432 for
waterbirths and 1 in 1450 for land births. Theories for the For those mothers seeking a physiologic birth with
rate phenomenon, according to Cohain, includes (1) minimal interventions, water labor and water birth
inoculating the baby with mother’s intestinal flora at birth are safe options and provide comfort in labor and
protects against GBS infection; (2) water washes off the relief of labor pain using a convenient non-
GBS bacteria acquired during the descent through the pharmacologic method.
vagina; (3) the water dilutes the GBS bacteria and mixes it
Waterbirth Workshops are available world-wide to
with a multitude of other intestinal bacteria that compete
provide childbirth educators, doulas, nurses, midwives
with GBS; (4) early onset GBS is elicited by complications
and physicians, with further research data to instill
and interventions at birth, which occur

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confidence, explore procedures, and reduce fear
(Russell, 2014).

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 Cluett, E. and Burns, E. (2009) Immersion in water in labour
The Need for More Research in and birth. Cochrane Database Systematic Review Issue 2,
N0. CD000111.
the Future
Cochrane Review http://summaries.cochrane.org/CD000111/
A joint statement was published from the American immersion-in-water-in-labour-and-birth.
Academy of Pediatrics (AAP) Committee on Fetus and
Newborn and the American College of Obstetricians and Cohain, J.S. (2010-11) Waterbirth and GBS. Midwifery Today
International Midwife. Winter: (96): 9-10.
Gynecologists (ACOG) Committee on Obstetric Practice
assessing the use of water as a part of labor and birth, Cortes, E., Basra, R., and Kellerher, C.J. (2011) Waterbirth and
relieving or shortening labor and adding to maternal pelvic floor injury: a retrospective study and postal survey
using ICIQ modular long form questionnaires. European
satisfaction (ACOG, 2014).
Journal of Obstetrics, Gynecology and Reproductive Biology,
Mar, 155(1): 27-30.
The report from the committees concluded that
“immersion in water may be appealing to some and Dahlen, H.G. et al. (2013) Maternal and perinatal outcomes
may be associated with decreased pain or use of amongst low risk women giving birth in water compared to six
birth positions on land. A descriptive cross sectional study in a
anesthesia and decreased duration of labor”. The report birth centre over 12 years. Midwifery, Jul, 29(7):759-64.
went further to state, “there is no evidence that
immersion in water during the first stage of labor Harding, C. et al. (2012) Evidence Based Guidelines for Midwifery-
Led Care in Labour: Immersion in Water for Labour and Birth.
otherwise improves perinatal outcomes.” Royal College of Midwives.

However, a Cochrane Review of the literature included Harper, B. (2012) In deep: Seven secrets of successful waterbirth.
12 trials (3243 women). Water immersion during the Essentially MIDIRS, Vol 3, No. 5.
first stage of labor significantly reduced epidural/ spinal Henderson, J. et al. (2014) Labouring women who used a birthing
analgesia without adversely affecting labor duration, pool in obstetrics units in Italy: prospective observational
operative delivery rates or neonatal well-being. One trial study. BMC Pregnancy Childbirth, Jan, 14: 14-17.
showed that immersion in water during the second stage Mollamahmutoglu, L. et al. (2012). The effects of immersion in
of labor increased women’s reported satisfaction with water on labor, birth and newborn and comparison with
their birth experience (Cochrane, 2009). epidural analgesia and conventional vaginal delivery. Journal of
the Turkish-German Gynecological Association, 13: 45-49.

Nutter, E. et al. (2014) Waterbirth: an integrative analysis of peer-

reviewed literature. Journal of Midwifery and Womens Health,
References May, 59(3): 350-4.
American College of Obstetricians and Gynecologists. (2014)
Russell, K. et al. (2014) Effecting change in midwives’ waterbirth
Immersion in water during labor and delivery. Committee
practice behaviours on labour ward: an action research study.
Opinion No. 594. Obstetrics & Gynecology, 123: 912-5. (Joint
Midwifery, Mar, 30(3): e96-e101.
statement with the American Academy of Pediatrics).
Schafer, R. (2014) Umbilical Cord Avulsion in Waterbirth. Journal of
Avery, M.D.(editor) (2013) Supporting a Physiologic Approach Midwifery and Womens Health, Vol. 59, No. 1.
to Pregnancy and Birth: A Practical Guide. Wiley-Blackwell
Publishing. Sprague, A. (2011) Water Labour, Water Birth: A guide to the use
of water during childbirth: A guide to the use of water during
pregnancy labour and birth. Annie Sprague; 4th edition.
International Childbirth Education Association

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