Water immersion during labour and birth is increasingly popular and is becoming widely
accepted across many countries, and particularly in midwifery‐led care settings. However,
there are concerns around neonatal water inhalation, increased requirement for admission
to neonatal intensive care unit (NICU), maternal and/or neonatal infection, and obstetric
anal sphincter injuries (OASIS). This is an update of a review last published in 2011.
To assess the effects of water immersion during labour and/or birth (first, second
and third stage of labour) on women and their infants. We searched Cochrane Pregnancy
and Childbirth’s Trials Register, ClinicalTrials.gov and the WHO International Clinical
Trials Registry Platform ( ICTRP ) (18 July 2017), and reference lists of retrieved
trials. We included randomised controlled trials (RCTs) comparing water immersion
with no immersion, or other non‐pharmacological forms of pain management during labour
and/or birth in healthy low‐risk women at term gestation with a singleton fetus. Quasi‐RCTs
and cluster‐RCTs were eligible for inclusion but none were identified. Cross‐over
trials were not eligible for inclusion. Two review authors independently assessed
trials for inclusion and risk of bias, extracted data and checked them for accuracy.
Two review authors assessed the quality of the evidence using the GRADE approach.
This review includes 15 trials conducted between 1990 and 2015 (3663 women): eight
involved water immersion during the first stage of labour; two during the second stage
only; four during the first and second stages of labour, and one comparing early versus
late immersion during the first stage of labour. No trials evaluated different baths/pools,
or third‐stage labour management. All trials were undertaken in a hospital labour
ward setting, with a varying degree of medical intervention considered as routine
practice. No study was carried out in a midwifery‐led care setting. Most trial authors
did not specify the parity of women. Trials were subject to varying degrees of bias:
the intervention could not be blinded and there was a lack of information about randomisation,
and whether analyses were undertaken by intention‐to‐treat. Immersion in water versus
no immersion (first stage of labour) There is probably little or no difference in
spontaneous vaginal birth between immersion and no immersion (83% versus 82%; risk
ratio (RR) 1.01, 95% confidence interval (CI) 0.97 to 1.04; 6 trials; 2559 women;
moderate‐quality evidence); instrumental vaginal birth (12% versus 14%; RR 0.86, 95%
CI 0.70 to 1.05; 6 trials; 2559 women; low‐quality evidence); and caesarean section
(5% versus 4%; RR 1.27, 95% CI 0.91 to 1.79; 7 trials; 2652 women; low‐quality evidence).
There is insufficient evidence to determine the effect of immersion on estimated blood
loss (mean difference (MD) ‐14.33 mL, 95% CI ‐63.03 to 34.37; 2 trials; 153 women;
very low‐quality evidence) and third‐ or fourth‐degree tears (3% versus 3%; RR 1.36,
95% CI 0.85 to 2.18; 4 trials; 2341 women; moderate‐quality evidence). There was a
small reduction in the risk of using regional analgesia for women allocated to water
immersion from 43% to 39% (RR 0.91, 95% CI 0.83 to 0.99; 5 trials; 2439 women; moderate‐quality
evidence). Perinatal deaths were not reported, and there is insufficient evidence
to determine the impact on neonatal intensive care unit (NICU) admissions (6% versus
6%; average RR 1.30, 95% CI 0.42 to 3.97; 2 trials; 1511 infants; I² = 36%; low‐quality
evidence), or on neonatal infection rates (1% versus 1%; RR 2.00, 95% CI 0.50 to 7.94;
5 trials; 1295 infants; very low‐quality evidence). Immersion in water versus no immersion
(second stage of labour) There were no clear differences between groups for spontaneous
vaginal birth (98% versus 97%; RR 1.02, 95% CI 0.96 to 1.08; 120 women; 1 trial; low‐quality
evidence); instrumental vaginal birth (2% versus 2%; RR 1.00, 95% CI 0.06 to 15.62;
1 trial; 120 women; very low‐quality evidence); caesarean section (0% versus 2%; RR
0.33, 95% CI 0.01 to 8.02; 1 trial; 120 women; very low‐quality evidence), and NICU
admissions (8% versus 11%; RR 0.78, 95% CI 0.38 to 1.59; 2 trials; 291 women; very
low‐quality evidence). Use of regional analgesia was not relevant to the second stage
of labour. Third‐ or fourth‐degree tears, and estimated blood loss were not reported
in either trial. No trial reported neonatal infection but did report neonatal temperature
less than 36.2°C at birth (9% versus 9%; RR 0.98, 95% CI 0.30 to 3.20; 1 trial; 109
infants; very low‐quality evidence), greater than 37.5°C at birth (15% versus 6%;
RR 2.62, 95% CI 0.73 to 9.35; 1 trial; 109 infants; very low‐quality evidence), and
fever reported in first week (2% versus 5%; RR 0.53, 95% CI 0.10 to 2.82; 1 trial;
171 infants; very low‐quality evidence), with no clear effect between groups being
observed. One perinatal death occurred in the immersion group in one trial (RR 3.00,
95% CI 0.12 to 72.20; 1 trial; 120 infants; very low‐quality evidence). The infant
was born to a mother with HIV and the cause of death was deemed to be intrauterine
infection. There is no evidence of increased adverse effects to the baby or woman
from either the first or second stage of labour. Only one trial (200 women) compared
early and late entry into the water and there were insufficient data to show any clear
differences. In healthy women at low risk of complications there is moderate to low‐quality
evidence that water immersion during the first stage of labour probably has little
effect on mode of birth or perineal trauma, but may reduce the use of regional analgesia.
The evidence for immersion during the second stage of labour is limited and does not
show clear differences on maternal or neonatal outcomes intensive care. There is no
evidence of increased adverse effects to the fetus/neonate or woman from labouring
or giving birth in water. Available evidence is limited by clinical variability and
heterogeneity across trials, and no trial has been conducted in a midwifery‐led setting.
Immersion in water in labour and birth What is the issue? To assess the effects of
water immersion (waterbirth) during labour and/or birth (first, second and third stage
of labour) on women and their infants. Why is this important? Many women choose to
labour and give birth in water (water immersion) and this practice is becoming more
popular in many countries, particularly in midwifery‐led units. Therefore, it is important
to understand more about the benefits of water immersion in labour and birth for women
and their newborns, along with any risks. It is important to examine whether immersion
in water during the first and/or the second stage of labour has the potential to maximise
women's ability to manage labour pain, and to have a normal birth without increasing
the risk of an adverse (harmful) event. Adverse events might be an increased risk
of infection for women and/or their newborn; an increased likelihood of a serious
tear to the perineum (the area between anus and vagina), and it may make estimating
blood loss more difficult in the event of a haemorrhage. In assessing the benefits,
we consider well‐being to cover both physical and psychological health. What evidence
did we find? We included 15 trials (3663 women). All the trials compared immersion
in water with no immersion in water: eight during the first stage of labour, two during
the second stage of labour (waterbirth) only, four during the first and second stages
of labour, and one early versus late immersion during the first stage of labour. The
evidence was of moderate to very low quality. No trial compared immersion in water
with other forms of pain management. Water immersion during the first stage of labour
probably results in fewer women having an epidural, but probably makes little or no
difference to the number of women who have a normal vaginal birth, instrumental birth,
caesarean section or a serious perineal tear. We are uncertain about the effect on
the amount of blood loss after birth because the quality of the evidence was very
low. Labouring in water also may make little or no difference to babies being admitted
to neonatal intensive care unit (NICU) or developing infections. Stillbirths and baby
deaths were not reported. Two trials compared water immersion during the second stage
(birth) with no immersion. We found that immersion may make little or no difference
in numbers of women who have a normal vaginal birth. It is uncertain whether immersion
makes any difference to instrumental vaginal births, caesarean sections, numbers of
babies admitted to NICU, babies' temperatures at birth and fever in babies during
the first week, because the quality of the evidence was found to be very low for all
of these outcomes. Epidurals were not relevant to this stage of labour. Serious perineal
tears and blood loss after birth were not reported in either trial. Only one trial
(200 women) compared women who got into the water early and late in their labour but
there was not enough information to show any clear differences between the groups.
What does this mean? Labouring in water may reduce the number of women having an epidural.
Giving birth in water did not appear to affect mode of birth, or the number of women
having a serious perineal tear. This review found no evidence that labouring in water
increases the risk of an adverse outcome for women or their newborns. The trials varied
in quality and further research is needed particularly for waterbirth and its use
in birth settings outside hospital labour wards before we can be more certain of these
effects. Research is also needed about women’s and caregivers experiences of labour
and birth in water.