Wondering about Water birth?

By Heather Pieterse.

Published in Sensitive Midwifery Magazine, April/June 2012.

The sigh of pure relief as a woman submerges her tired and aching body into the warm bath is one of the defining moments of water birth for me, says independent midwife Heather Pieterse.

Midwives around the world who assist women who prefer to labour and give birth in water, can attest to the truth of the scene that Heather eloquently goes on to sketch. “No matter how much information she has gathered, a mother-to-be’s expectations are always exceeded as the warm water almost instantly affects all her senses, dulling the pain and enhancing the relaxation as adrenaline, oxytocin and endorphins dance through her body, setting the pace for an uninterrupted birth of her baby. Soon after the warm water has taken effect there may be a little concern that the contractions seem to have miraculously become fewer, less strong or stopped. All it takes is a little reassurance that this is normal and she calmly relaxes and enjoys the peace, gathering her energy and soon being ready to continue the long journey towards meeting her baby face to face.”

Water talk

Giving birth in water is no longer seen as unusual. There has been a huge increase in research published on the benefits of water in labour and for birth over the past 15 years. Many women are now aware that they have the right to make informed choices about the type of birth they would prefer and they search for the place and person who can provide what they want. Various nursing education institutions now include water birth in their curriculum and hospitals are increasingly installing baths in their labour ward facilities.

For years guidelines have recommended that water should be made available to women who choose to use it in labour or for birth. All midwives should be trained to support women in water so that when faced with this request in labour ward, they will feel competent to assist them to have a positive and safe birth experience.

Who can labour and birth in water?

All women who have low risk, healthy pregnancies should be given the opportunity to use water to aid relaxation and pain relief in labour. If there are no adverse factors noted in foetal or maternal wellbeing during labour, water immersion can be offered. A baseline assessment of both mother and baby should be done before submerging in the tub and continued throughout the time spent in the water, as for any normal labour. An aqua-dopler should be used for foetal monitoring whilst in the water so the woman in labour is not disturbed unnecessarily. Usual foetal monitoring guidelines are adhered to as with a normal birth. If vaginal examinations are necessary they can be performed in the water.

Sadly though, there are still misconceptions about water birth and negative attitudes in health care professionals still prevail, despite much research-based evidence proving that with good preparation and following proper protocols, there is no more risk than with a normal non-water birth. In fact, there are many added benefits linked to labouring and giving birth in water. Women have a right to preferences and choice relating to their births, and the right to find a facility and caregiver that can assist them with these choices. Midwives have a responsibility to be up to date and to be a spokesperson or advocate for the women we have chosen, by virtue of our selection of profession, to care for and support through labour and birth. Negative attitudes in health care professionals not only make women who seek this option feel unsure about themselves, but also undermine the medical profession as a whole. One only has to do a simple Internet search to find the latest research based evidence at one’s fingertips.

What research says

There are clear medical advantages to using water in labour and birth:

  • Significantly shorter labour durations amongst primips 1,2, 3, 5,7
  • Significantly reduced need for labour augmentation 7,10
  • A reduction in episiotomy rate 1,2,3,5,6,7
  • A marked drop in the use of analgesia 1,2,3,4,5,6,7

Compared to traditional vaginal birth not in water, research shows that:

  • The risk of perineal tearing/trauma was found to be the same as a non-water birth (1, 2, 3)
  • There were no differences in the duration of the second stage (3)
  • There was no differences in arterial cord blood pH and base excess (2)
  • Postpartum maternal haemoglobin levels remained unchanged (1)
  • There was no significant difference in the risk of maternal infection (4)
  • There was no difference in the rate of assisted vaginal deliveries or Caesarean section when using water during labour (4)
  • There were no differences for Apgar score less than seven at five minutes, neonatal unit admissions, or neonatal infection rates (4)

What about the risk of infection?

Whilst the potential risk of infection to the neonate is documented in various articles (1, 3, 4) due to the fact that foecal matter is often released into the water during the expulsion stage of birth, it was still found that there was no significant increase of admissions to neonatal ICU. This is thought to be due to the baby having colonised beneficial bacteria from the mother.

Point to ponder: When a woman births in bed, her baby is in any event born with its face just centimetres from the rectum!

Research shows there was less frequency of Group B Streptococcus colonization with babies born in water than babies born out of the water, even in the event of preterm rupture of membranes. It is thought that this could be attributed to a washout effect which protects babies during delivery. 8,9

Positive midwifery power

Midwives often underestimate the influence they have on the outcome of each and every birth they assist with. With knowledge and experience usually comes confidence. It is essential to truly understand the reasons women choose to use water in labour and birth, to keep up to date and to ensure that safe midwifery is practiced. Once midwives feel safe in their practice, confidence will grow and more women will be given the choice to use water. Midwives should and can be advocates for their patients and initiate the process to have birthing pools installed in every institution where normal vaginal birth for healthy women is on offer.

Midwife Heather Pieterse touchingly concludes her plea for choice for women and for midwives to encompass water birth as an option: “As baby’s head slowly emerges, the woman reaches down and touches it. A look of complete incredulity is quickly followed by a renewed surge of energy as she realises without a doubt that she will be meeting her baby within moments. The head is born and baby’s body soon glides out into the water, eyes open and seemingly already searching for mom. The cord unravels from around the little body as baby spirals and frees herself without panic or fuss. The mother reaches down and gently takes hold of her baby and lifts her out of the water. This is the moment we have all been waiting for and an incredible look of pure delight crosses the mother’s face. Baby looks around trying to find the one voice she recognises, slowly takes her first breath and starts to cry. A perfect end to a long but perfect day – the ‘birth day’ that will always be remembered in the finest detail by the mother. What a privilege to have been the midwife who was able to facilitate this joyous experience.”


  1. Minerva Ginecol. 2005 Apr;57(2):199-206. – Italy. Water birth and neonatal infections. Experience with 1575 deliveries in water. Thöni A, Zech N, Moroder L
  2. Gynakol Geburtshilfliche Rundsch. 2007;47(2):76-80. – Germany. Giving birth in the water: experience after 1,825 water deliveries. Retrospective descriptive comparison of water birth and traditional delivery methods. Thöni A, Zech N, Ploner F.
  3. Minerva Ginecol. 2010 Jun;62(3):203-11. Italy. Water birthing: retrospective review of 2625 water births. Contamination of birth pool water and risk of microbial cross-infection. Thöni A, Mussner K, Ploner F.
  4. Cochrane Database – 2009 (Assessed as up to date in August 2011) Immersion in water in labour and birth. Cluett ER, Burns E.
  5. J Matern Fetal Neonatal Med. 2005 May;17(5):357-61. – Italy. Review of 1600 water births. Does water birth increase the risk of neonatal infection? Thoeni A, Zech N, Moroder L, Ploner F.
  6. European Journal of Obstet Gynecol Reprod Biol. 2000 Jul;91(1):15-20. – UK. A retrospective comparison of water births and conventional vaginal deliveries. Otigbah CM, Dhanjal MK, Harmsworth G, Chard T.
  7. Wien Klin Wochenschr. 2002 Jun 14;114(10-11):391-5. – Austria. Effects of water birth on maternal and neonatal outcomes. Bodner K, Bodner-Adler B, Wierrani F, Mayerhofer K, Fousek C, Niedermayr A, Grünberger W.
  8. Arch Gynecol Obstet. 2006 Jan;273(4):236-8. Epub 2005 Oct 6. Water birth: is the water an additional reservoir for group B streptococcus? Zanetti-Dällenbach R, Lapaire O, Maertens A, Frei R, Holzgreve W, Hösli I.
  9. RCOG – Group B strep and water birth – query bank – November 2011
  10. BMJ. 2004 Feb 7;328(7435):314. Epub 2004 Jan 26. Randomised controlled trial of laboring in water compared with standard of augmentation for management of dystocia in first stage of labour. Cluett ER, Pickering RM, Getliffe K, St George Saunders NJ