Overview

Hydrotherapy is a broad term that encompasses many different treatments around the physical properties of water like temperature and pressure. In this article, we explore the use of water during labor. Proponents of water birth claim that it is beneficial in managing discomfort from contractions, that it promotes relaxation and eases stress for your baby during birth. Critics of the practice raise concerns about the safety of water births and risks associated with respiratory issues for the baby, and the risk of infection for both you and your baby. This article examines the evidence and safety of waterbirth, as well as alternative ways to utilize water during labor at home or in a birth center or hospital.

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Hydrotherapy

Hydrotherapy is the use of water for health purposes. This is a broad term that encompasses many different treatments around the physical properties of water like temperature and pressure. In this article, we explore the use of water in labor by birthing in water or even taking a bath or shower. I know waterbirth is not for everyone, and this article starts with some alternative ways to utilize water during labor, then dives into the evidence on waterbirth.

Showers at Home and in the Hospital

You can try a shower either at home or once you are in the hospital. It is easy to instantly adjust the temperature in a shower if you prefer warmer or cooler water. The sensation of the water on your back can be soothing, especially if you have a shower head with different settings. You may also want to try putting a plastic chair in the shower and sit on it backwards to get the shower on your back. Getting in the shower at a hospital may not be an option once you get an epidural. If your care provider monitors your baby with an electronic fetal monitor, you can request to remove it while you are in the shower.

In a study of 80 participants, 39 had warm showers during labor for 20 minutes at a time. They found that warm showers improved the birth experience and decreased labor pain. Another study that utilized 30-minute showers during active labor found the showering group had statistically significant decreases in pain, discomfort, anxiety and tension, and a significant increase in relaxation. There were no differences in the use of obstetric interventions.

Showering is an evidence-based tool to try during labor that has no downside. If it isn’t helpful, you can always get out.

Baths at Home

You can take a bath in the early stages of labor at home. You want the temperature warm but not scalding hot, so you avoid overheating. Your body is working very hard during labor, and you may already feel on the warm side. You may find a warm bath to be relaxing, and you may experience some relief during contractions. There is not a downside to trying a bath. If it isn’t helpful, you can always get out and drain the bathtub.

Upright Positions

One significant benefit of being seated upright in a bathtub or standing or sitting in a shower is that you are in an upright position. You should adjust your positions in labor as needed throughout your labor. There is evidence to support laboring in an upright position. Being upright uses gravity in your favor to help your baby descend in the birth canal. In a review of women during the first stage of labor, overall, it was concluded that there is clear and important evidence that walking and upright positions in the first stage of labor reduce labor duration, the risk of cesarean birth, the need for an epidural. Plus, being upright does not seem to be associated with increased intervention or negative effects on mothers’ and babies’ well-being.

Even after you are out of the bath or shower, there are benefits to being upright in the second stage of labor. A study concluded women should be encouraged to move and deliver in the most comfortable position for them. This study compared women giving birth in an upright position to women who labored and gave birth lying down. Women who used upright positions more than 50% of the time had more effective uterine contractions and more perineal muscle relaxation, and their births were significantly shorter. In addition, they had lower rates of requests for epidurals or other medication, less assisted deliveries, and less cesarean sections. Researchers found no differences in terms of neonatal outcomes.

Water Birth

Waterbirth is a birth in which a baby is born to a mother laboring in a tub of water. There are legends of women in different cultures laboring in water, but there isn’t documentation of anyone giving birth in water until 1803 in France. It wasn’t until the 1980’s that the popularity of water births began growing in Western cultures. Proponents of water birth claim that it is beneficial in the management of discomfort from contractions, that it promotes relaxation and eases stress for your baby during birth. Critics of the practice raise concerns about the safety of water births and risks associated with respiratory issues for the baby, and the risk of infection for both you and your baby.

First Stage of Labor

The risks and benefits of utilizing water during labor differ in the different stages of labor. The first stage of labor is when your cervix is dilating and effacing. The first stage goes from the start of labor until your cervix is dilated to 10 cm and is fully effaced. Water immersion could be helpful in the first stage of labor, even if you are not planning to birth your baby in the tub. In a tub of warm water, you are free to move around in different positions and may find some relief from the buoyancy of water. 

Your labor is going to progress best when you are comfortable. Your needs and the positions you choose will evolve as your labor progresses. It is possible you find being a tub wonderful in the beginning and at some point decide you prefer to be on dry land. Give yourself some room to change your plans if needed and if at any point a tub isn’t working for you, get out and try something else. You can always get back in. 

Second Stage of Labor

The second stage is the pushing stage. This goes from your cervix being fully dilated and effaced until your baby is born. The pushing stage has both pros and cons if you are in a tub of water, and not all care providers support mothers being in the water for the second stage of labor. (More on this later in this article when diving into the research.)

Can Your Baby Drown?

One of the most common questions about this practice is whether your baby could drown underwater. The first thing you should know is that your baby’s oxygen supply is coming through the umbilical cord. Your doctor or midwife monitors your baby’s oxygen supply by their heart rate. If your baby is not getting enough oxygen from the placenta, their heart rate slows down. Your care provider will be intermittently monitoring your baby’s heart rate with a hand help waterproof Doppler. A complex chain reaction takes place once a baby is born that initiates their first breath of air. Once your baby is born, you or your care provider would gently lift them out of the water, where they would take their first breath of air. You wouldn’t leave them in the water for an extended period. With an experienced practitioner, you should not be concerned about your baby drowning.

If you choose to have an underwater birth, you should know that babies will gain more color in their skin following birth. It is common for babies born in water to take a little bit longer to get their color. The transition from womb to warm water is different from the transition from womb to cooler air. This is why when you see photos of water births, the baby always appears pale right after birth.

Professional Organization Opinions

Most water births are in community birth settings. The Commission for the Accreditation of Birth Centers has guidelines and recommendations for birth centers offering water birth. These guidelines include specific details on exclusion criteria, water temperature, maternal and fetal assessment while in the water, tub cleaning protocols, staff training, and emergency drills addressing the management of complications. Any practitioner who is offering water birth and any birth center with water births as an option should be following guidelines to ensure the safety of you and your baby.

Midwives attend most waterbirths, and the American College of Nurse-Midwives has a statement on hydrotherapy during labor and birth in support of water birth. The ACNM states warm water immersion hydrotherapy during labor provides comfort, supports relaxation, and is a safe and effective non-pharmacologic pain relief strategy that promotes physiologic childbirth. Women should be given the opportunity to remain immersed during labor and birth if they wish to do so within the context of a shared decision-making process with their health care providers.

While water births are increasing, most births in the United States take place in a hospital setting. Two central authorities on pregnancy and childbirth, the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists, agree on the official opinion issued on water births. The opinion states immersion in water during the first stage of labor may be associated with a shorter labor and decreased use of spinal and epidural analgesia and may be offered to healthy women with uncomplicated pregnancies between 37 0/7 weeks and 41 6/7 weeks of gestation. 

They state there is insufficient data on which to draw conclusions regarding the relative benefits and risks of immersion in water during the second stage of labor and delivery. Therefore, until such data are available, it is the recommendation of the American College of Obstetricians and Gynecologists that birth occurs on land, not in water. A woman who requests to give birth while submerged in water should be informed that the maternal and perinatal benefits and risks of this choice have not been studied sufficiently to either support or discourage her request. 

This opinion was released in 2016 and reaffirmed in 2021. This was different than the 2014 opinion where ACOG stated that the practice of an underwater delivery should be considered an experimental procedure that only should be performed within the context of an appropriately designed clinical trial with informed consent. This change may seem insignificant, and although ACOG still recommends birth occur on land, they acknowledge that this should be an informed consent choice. As water birth is becoming more popular, and as more expecting parents are requesting it, we may see more support from organizations like ACOG in the future.

The Evidence on Water Birth

A Cochrane review, including 15 trials with 3,663 women, broke down findings by the stage of labor. For immersion in the first stage of labor, they found a small reduction in the risk of using regional analgesia (epidural) for women using water immersion from 43% to 39%. If a water birth takes place at home or a birth center, epidurals are not available. All of the trials included in this review were in a hospital setting, where regional anesthesia would be an option. The review found there is probably little or no difference in a spontaneous vaginal birth, instrumental birth, and cesarean section. There was insufficient evidence to determine whether immersion in water in the first stage of labor affected blood loss, third or fourth-degree vaginal tears. There was insufficient evidence to determine the impact on neonatal intensive care unit (NICU) admissions or neonatal infection as far as babies’ outcomes. In the second stage of labor, there were no clear differences for spontaneous vaginal birth, instrumental birth, cesarean section, and NICU admissions. Overall, this review found no evidence of increased adverse effects to the baby or woman from either the first or second stage of labor.

A study found that water births had shorter second and third labor stages than vaginal deliveries, both with and without an epidural. The mean second stage in the water birth group was 10.9 minutes, compared to 28.3 minutes in the epidural group and 23.9 minutes in the conventional group.

A study of 2,625 water births found shorter labor duration, a net reduction in episiotomy rates, and a marked drop in requests for pain relievers. The study mentions that fecal matter is released into the birth pool water during the birth of the baby, contaminating it with microorganisms. Despite this, water birthing was found to be safe for the baby and did not carry a higher risk of neonatal infection when compared with conventional vaginal delivery. The concern of infection is one of the most cited reasons against water birth, so this was an important study in that it found women and babies were not at an increased risk for infection due to birthing in water.

A large study of 26,684 women who gave birth at home or a birth center included 10,252 women who gave birth in water. The mothers who gave birth in water were less likely to use pain medication, significantly less likely to experience an episiotomy or laceration, and less likely to experience an FHR abnormality. The occurrence of prolonged first and second stages of labor was lower in women having a water birth. There were also fewer instances of shoulder dystocia for water births and fewer hospital transfers. Babies born in water were less likely to be transferred to a hospital, be admitted to the NICU, or experience respiratory complications. There were no significant differences in Apgar scores, neonatal death, or newborn readmission. The study authors note that findings favoring water birth over land birth in this sample were likely attributable to the appropriate utilization of policies, procedures, risk screening, and expertise of the nurses and midwives caring for the families. 

Summarizing the Research

To sum up all of the different studies and opinions, there is no evidence that mothers or babies in water births are at an increased risk for infection or other adverse outcomes. The midwife community is very supportive of water birth, and the Ob-Gyn community still has some concerns. The American Academy of Pediatrics and the American Congress of Obstetricians and Gynecologists are comfortable with the mother laboring during the first stage of labor in water but recommends birth be on land. You should now have a lot of information to help you decide whether you would be comfortable with a water birth or whether it is an option you would consider. 

Are You a Candidate for Waterbirth?

Waterbirth may be an option for you if you are planning unmedicated labor and are considered low-risk. An epidural involves a catheter in your lower back that continuously delivers medication, which is not compatible with being in a tub. You may have access to nitrous oxide if your care provider offers that. Typically, water birth is unmedicated.

To have a water birth, you will need to plan to have your baby at a venue that supports water birth. Your care provider needs to support the practice and have experience attending water births. While more hospitals are beginning to offer this as an option, most water births are taking place in homes or at birth centers under the care of a midwife. Typically, to be a home or birth center birth candidate, you need to be low-risk. This is loosely defined as pregnant with a single baby, in a head-down position, without any complications. Conditions like insulin-dependent gestational diabetes or hypertension may exclude you as a candidate from a home or birth center birth.

Exploring Your Options 

If you are interested in water birth, the first step is to discuss your options with your care provider and make sure you are a good candidate given the specifics of your pregnancy and any possible risk factors. There are several reasons why a water birth may not be an option for you. Your care provider may have concerns due to the particulars of your pregnancy. The hospital you plan to give birth may have a policy against waterbirth. Depending on where you plan to birth, you may not have access to a tub. You can advocate for yourself if you want a waterbirth and you think you are a good candidate. If there is not a permanent tub available, you may be able to bring in an inflatable tub. If your doctor or midwife is reluctant to support your birthing in the water, you can always ask why or point out that ACOG supports allowing mothers to be in the water for the first stage of labor.

Waterbirth Positions

As with a bath or shower, laboring in water promotes you being in an upright position. Some of the most common positions are seated and reclined back, on your hands and knees, or seated back on your knees. A tub gives you the freedom to move and try different positions to find what works best for you at that particular time.

Permanent vs. Inflatable Tubs

An ideal tub for labor and birth is larger than a standard bathtub and can be a built-in bathtub or a portable inflatable pool. If you are planning a water birth at a hospital or birth center, the chances are that a permanent tub is in place, and the hospital or birth center will provide anything needed.

If a built-in tub is not available, you can use an inflatable tub. Pools specifically for birth are sturdier and deeper than inflatable pools you would get for your kids to play in your backyard.

If you choose to purchase a tub, you can expect to pay somewhere around $200-400. Amazon does not sell birth pools. There are some websites specifically marketing for waterbirth or medical supply companies that offer inflatable tubs for sale. Shipping times will vary, and at the time of this article, several websites list the tubs as back-ordered. If you are planning to purchase a tub, plan so you have plenty of time for it to arrive.

A less expensive option would be to rent a birth pool, and prices are usually about half of what you pay to buy your own, and you typically have the rental for a month around your due date. Start with asking your midwife or doula if they have a pool or have recommendations on the best place to rent a tub in your area. Inflatable tubs use a liner, so if someone has used the tub before you, they also used a liner, and anyone who rents these out should be taking care to clean them in between uses thoroughly.

Inflatable Tub Accessories

If you purchase or rent a tub, you may need a few accessories in addition to a disposable liner. Check with your care provider or the company you buy or rent a pool from to see if they include these items.

Hose: Garden hoses can contain chemicals, which is why you want a hose specifically for potable water. Ensure the hose is long enough to go from a faucet to the location you plan to put your tub. You may also need a connector to attach the hose to your faucet, and the best faucet is likely in your kitchen. You may also be able to connect it to your shower.

Electric air pump: you may want to choose a pump that plugs in, so you do not need to worry about charging it.

Thermometer: Any floating pool or hot tub thermometer

Debris removal net: A small aquarium net to pull debris out of the tub. Yes, it is true you might poop during labor. That may sound terrifying, but it isn’t a big deal.

Electrical water pump: you can use a water pump to empty the pool. You can also siphon water out with the hose or use a bucket to drain the pool if needed.

Pool cover: you can purchase a cover for the pool to help it retain heat when you are not in it. If you choose a cover, please make sure it is compatible with the pool model.

Tarp or shower curtain liner: a plastic sheet like a tarp or shower curtain liner can be placed under the pool to protect your floor from spills.

Water Temperature

The water temperature is usually between 92-100° Fahrenheit (33-38°Celsius). The water temperature is cooler than a hot tub because you want to avoid elevating your core body temperature and overheating.

What to Wear

During labor, you will be naked from the waist down. Some women choose to wear a sports bra or top, and others prefer not to wear anything. Whether you are nude or partially covered is ultimately up to you and your comfort level.

Water Birth and Your Partner

Your partner may be able to join you if the tub is big enough for a second person. If your partner is joining you, they should be in swimwear, so be sure to pack that in your birth bag. If your partner is in the tub with you, a comfortable position may be to have them seated behind you so you can lean back and have them support you.

Including Hydrotherapy in Your Birth Plan

If you have listened to the past episode on creating your birth plan, or read the Your Birth Plan book, you know it is crucial to work with your care provider to create your birth plan. You may want to include a waterbirth or hydrotherapy in the form of a shower in your written birth plan. If you are having trouble getting started with your birth plan and want to see a sample, you can click here and get a free copy of my birth plan. Your preferences may be different from mine, but it could help get an idea of how a birth plan could be structured or worded.

If, after hearing all of the information and research in this episode, you do not feel like water birth is a safe option or the best option for you, that is okay. There is no one size fits all for everyone, and it is up to you to decide what will be best for you and your baby. Even if you are not planning a water birth, you may want to try a bath or shower during labor.

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