Studies on waterbirth and VBAC
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20090506-82* Immersion in water in labour and birth (Cochrane Review). (Last assessed as up-to-date: 19 November
2008) - The Cochrane Database of Systematic Reviews , Issue 2, 2009 Cluett ER; Burns E - (2009)
Background: Enthusiasts suggest that labouring in water and waterbirth increase maternal relaxation, reduce analgesia
requirements and promote a midwifery model of care. Sceptics cite the possibility of neonatal water inhalation and
maternal/neonatal infection. Objectives: To assess the evidence from randomised controlled trials about immersion in
water during labour and waterbirth on maternal, fetal, neonatal and caregiver outcomes. Search strategy: We searched
the Cochrane Pregnancy and Childbirth Group's Trials Register (October 2008). Selection criteria: Randomised controlled
trials comparing any bath tub/pool with no immersion during labour and/or birth. Data collection and analysis: We
assessed trial eligibility and quality and extracted data independently. One review author entered data and another
checked for accuracy. Main results: This review includes 11 trials (3146 women); eight related to the first stage of labour,
one to the first and second stages, one to early versus late immersion in the first stage of labour, and another to the
second stage. We identified no trials evaluating different baths/pools, or the management of third stage of labour. Results
for the first stage of labour showed there was a significant reduction in the epidural/spinal/paracervical
analgesia/anaesthesia rate amongst women allocated to water immersion compared to controls (478/1254 versus
529/1245; odds ratio (OR) 0.82, 95% confidence interval (CI) 0.70 to 0.98, six trials). There was no difference in assisted
vaginal deliveries (OR 0.84, 95% CI 0.66 to 1.06, seven trials), caesarean sections (OR 1.23, 95% CI 0.86 to 1.75, eight
trials), perineal trauma or maternal infection. There were no differences for Apgar score less than seven at five minutes
(OR 1.59, 95% CI 0.63 to 4.01, five trials), neonatal unit admissions (OR 1.06, 95% CI 0.70 to 1.62, three trials), or
neonatal infection rates (OR 2.01, 95% CI 0.50 to 8.07, five trials). A lack of data for some comparisons prevented robust
conclusions. Further research is needed. Authors' conclusions: Evidence suggests that water immersion during the first
stage of labour reduces the use of epidural/spinal analgesia. There is limited information for other outcomes related to
water use during the first and second stages of labour, due to intervention and outcome variability. There is no evidence of
increased adverse effects to the fetus/neonate or woman from labouring in water or waterbirth. The fact that use of water
immersion in labour and birth is now a widely available care option for women threatens the feasibility of a large,
multicentre randomised controlled trial. (Author)
20090619-95 A randomised controlled trial evaluating the effect of immersion bath on labour pain - Midwifery , vol 25,
no 3 June 2009, pp 286-294 da Silva FMB; de Oliveira SMJV; Nobre MRC - (2009)
OBJECTIVE: to evaluate the effect of an immersion bath on pain magnitude during the first stage of labour. DESIGN: a
randomised controlled trial comparing the pain scores of bathing and non-bathing nulliparous women during birth was
employed. SETTING: the study was conducted at the Normal Birth Center of Amparo Maternal, São Paulo, Brazil.
PARTICIPANTS: 108 birthing women, with 54 women randomly assigned to each group. INTERVENTIONS: when the
birthing women presented at 6-7 cm of cervical dilation, they were placed in an immersion bath for 60 mins. OUTCOME
MEASURES: pain scores, using a behavioural pain scale and a numeric scale, were recorded at two evaluation time
points: at 6-7 cm of cervical dilation and 1h after the first pain score evaluation. FINDINGS: at the first evaluation, on the
behavioural scale, the means were 2.1 for both groups (p=0.914; 95% confidence intervals (CI) 1.9-2.3 for the control
group and 2.0-2.2 for the experimental group). On the numeric scale, the means were 8.7 and 8.5 for the control and
experimental groups, respectively (p=0.235; 95% CI 8.2-9.2 for the control group and 8.1-8.9 for the experimental group).
At the second evaluation, the pain score means for both scales were statistically higher in the control group than in the
experimental group. On the behavioural scale, the scores were 2.4 vs. 1.9, respectively, for the control and experimental
groups (p<0.001; 95% CI 2.2-2.6 for the control group and 1.7-2.1 for the experimental group). On the numeric scale, the
scores were 9.3 vs. 8.5, respectively, for the control and experimental groups (p<0.05; 95% CI 8.9-9.7 for the control group
and 8.1-8.9 for the experimental group). CONCLUSIONS: mean labour pain scores in the control group were significantly
higher than those in the experimental group. The present findings suggest that use of an immersion bath is a suitable
alternative form of pain relief for women during labour. (19 references) (Author)
20090904-56 Immersion in water: use of a pool by women in labour - British Journal of Midwifery , vol 17, no 9,
September 2009, pp 583-587 Jessiman WC - (2009)
Since 1997 women in a consultant-led unit in Inverness have had access to a purpose-designed pool for labour and
birth. The number of women using the pool over the last 11 years has steadily increased and midwives have gained more
experience and confidence in the use of the pool for labour and birth. This article describes the ongoing evaluation of the
pool from September 1997 to December 2008 and identifies how the experience in Inverness varies from other units in
the UK. (26 references) (Author)
20090922-115 Waterbirth: Is it a real choice? - Midwifery Matters , no 122, Autumn 2009, pp 9-12 Benko A - (2009)
Reviews the use of birthing pools during labour, including the advantages of using water for pain relief, the
considerations for high-risk pregnancies, and the benefits of water for specific conditions, including obesity, hypertension,
previous caesarean section, infection, and diabetes. Concludes that midwives need to provide appropriate, evidence-
based, information on the use of birthing pools to allow women to make an informed choice about their birth experience.
(32 references) (TC)
20091001-12 Letter from Europe: Water birth: Just a fad? - Birth , vol 36, no 3, September 2009, pp 258-260 Kitzinger
S - (2009)
Summarises the use of birth pools throughout Europe where many countries have abandoned the practice due to fears
for the baby's safety. Concentrates on the United Kingdom where this method of delivery is relatively widespread and
supported by the National Health Service, and makes recommendations for reducing risks. Examines attitudes of
midwives and other health personnel, and outlines some of the advantages of this method of birth. (11 references) (JR)
20090408-15 Waterbirth in New Zealand: Herstory and politics - Birthspirit Midwifery Journal , no 1, February 2009,
pp 13-19 Banks M - (2009)
The contentious start waterbirth had in New Zealand in the 1980s is explored in this article, along with some issues
which now impact on midwifery practice and women’s experiences as waterbirth becomes increasingly available in
obstetric hospital settings. (34 references) (Author)
20090408-23 Going with the flow – An alternative perspective on VBAC - Birthspirit Midwifery Journal , no 1, February
2009, pp 47-50 Davies L - (2009)
A practice incident triggered renewed reflection on the evidence relating to vaginal birth after Caesarean section (VBAC),
and the option of waterbirth in a tertiary care setting for a subsequent labour and birth. (20 references) (Author)
2008) - The Cochrane Database of Systematic Reviews , Issue 2, 2009 Cluett ER; Burns E - (2009)
Background: Enthusiasts suggest that labouring in water and waterbirth increase maternal relaxation, reduce analgesia
requirements and promote a midwifery model of care. Sceptics cite the possibility of neonatal water inhalation and
maternal/neonatal infection. Objectives: To assess the evidence from randomised controlled trials about immersion in
water during labour and waterbirth on maternal, fetal, neonatal and caregiver outcomes. Search strategy: We searched
the Cochrane Pregnancy and Childbirth Group's Trials Register (October 2008). Selection criteria: Randomised controlled
trials comparing any bath tub/pool with no immersion during labour and/or birth. Data collection and analysis: We
assessed trial eligibility and quality and extracted data independently. One review author entered data and another
checked for accuracy. Main results: This review includes 11 trials (3146 women); eight related to the first stage of labour,
one to the first and second stages, one to early versus late immersion in the first stage of labour, and another to the
second stage. We identified no trials evaluating different baths/pools, or the management of third stage of labour. Results
for the first stage of labour showed there was a significant reduction in the epidural/spinal/paracervical
analgesia/anaesthesia rate amongst women allocated to water immersion compared to controls (478/1254 versus
529/1245; odds ratio (OR) 0.82, 95% confidence interval (CI) 0.70 to 0.98, six trials). There was no difference in assisted
vaginal deliveries (OR 0.84, 95% CI 0.66 to 1.06, seven trials), caesarean sections (OR 1.23, 95% CI 0.86 to 1.75, eight
trials), perineal trauma or maternal infection. There were no differences for Apgar score less than seven at five minutes
(OR 1.59, 95% CI 0.63 to 4.01, five trials), neonatal unit admissions (OR 1.06, 95% CI 0.70 to 1.62, three trials), or
neonatal infection rates (OR 2.01, 95% CI 0.50 to 8.07, five trials). A lack of data for some comparisons prevented robust
conclusions. Further research is needed. Authors' conclusions: Evidence suggests that water immersion during the first
stage of labour reduces the use of epidural/spinal analgesia. There is limited information for other outcomes related to
water use during the first and second stages of labour, due to intervention and outcome variability. There is no evidence of
increased adverse effects to the fetus/neonate or woman from labouring in water or waterbirth. The fact that use of water
immersion in labour and birth is now a widely available care option for women threatens the feasibility of a large,
multicentre randomised controlled trial. (Author)
20090619-95 A randomised controlled trial evaluating the effect of immersion bath on labour pain - Midwifery , vol 25,
no 3 June 2009, pp 286-294 da Silva FMB; de Oliveira SMJV; Nobre MRC - (2009)
OBJECTIVE: to evaluate the effect of an immersion bath on pain magnitude during the first stage of labour. DESIGN: a
randomised controlled trial comparing the pain scores of bathing and non-bathing nulliparous women during birth was
employed. SETTING: the study was conducted at the Normal Birth Center of Amparo Maternal, São Paulo, Brazil.
PARTICIPANTS: 108 birthing women, with 54 women randomly assigned to each group. INTERVENTIONS: when the
birthing women presented at 6-7 cm of cervical dilation, they were placed in an immersion bath for 60 mins. OUTCOME
MEASURES: pain scores, using a behavioural pain scale and a numeric scale, were recorded at two evaluation time
points: at 6-7 cm of cervical dilation and 1h after the first pain score evaluation. FINDINGS: at the first evaluation, on the
behavioural scale, the means were 2.1 for both groups (p=0.914; 95% confidence intervals (CI) 1.9-2.3 for the control
group and 2.0-2.2 for the experimental group). On the numeric scale, the means were 8.7 and 8.5 for the control and
experimental groups, respectively (p=0.235; 95% CI 8.2-9.2 for the control group and 8.1-8.9 for the experimental group).
At the second evaluation, the pain score means for both scales were statistically higher in the control group than in the
experimental group. On the behavioural scale, the scores were 2.4 vs. 1.9, respectively, for the control and experimental
groups (p<0.001; 95% CI 2.2-2.6 for the control group and 1.7-2.1 for the experimental group). On the numeric scale, the
scores were 9.3 vs. 8.5, respectively, for the control and experimental groups (p<0.05; 95% CI 8.9-9.7 for the control group
and 8.1-8.9 for the experimental group). CONCLUSIONS: mean labour pain scores in the control group were significantly
higher than those in the experimental group. The present findings suggest that use of an immersion bath is a suitable
alternative form of pain relief for women during labour. (19 references) (Author)
20090904-56 Immersion in water: use of a pool by women in labour - British Journal of Midwifery , vol 17, no 9,
September 2009, pp 583-587 Jessiman WC - (2009)
Since 1997 women in a consultant-led unit in Inverness have had access to a purpose-designed pool for labour and
birth. The number of women using the pool over the last 11 years has steadily increased and midwives have gained more
experience and confidence in the use of the pool for labour and birth. This article describes the ongoing evaluation of the
pool from September 1997 to December 2008 and identifies how the experience in Inverness varies from other units in
the UK. (26 references) (Author)
20090922-115 Waterbirth: Is it a real choice? - Midwifery Matters , no 122, Autumn 2009, pp 9-12 Benko A - (2009)
Reviews the use of birthing pools during labour, including the advantages of using water for pain relief, the
considerations for high-risk pregnancies, and the benefits of water for specific conditions, including obesity, hypertension,
previous caesarean section, infection, and diabetes. Concludes that midwives need to provide appropriate, evidence-
based, information on the use of birthing pools to allow women to make an informed choice about their birth experience.
(32 references) (TC)
20091001-12 Letter from Europe: Water birth: Just a fad? - Birth , vol 36, no 3, September 2009, pp 258-260 Kitzinger
S - (2009)
Summarises the use of birth pools throughout Europe where many countries have abandoned the practice due to fears
for the baby's safety. Concentrates on the United Kingdom where this method of delivery is relatively widespread and
supported by the National Health Service, and makes recommendations for reducing risks. Examines attitudes of
midwives and other health personnel, and outlines some of the advantages of this method of birth. (11 references) (JR)
20090408-15 Waterbirth in New Zealand: Herstory and politics - Birthspirit Midwifery Journal , no 1, February 2009,
pp 13-19 Banks M - (2009)
The contentious start waterbirth had in New Zealand in the 1980s is explored in this article, along with some issues
which now impact on midwifery practice and women’s experiences as waterbirth becomes increasingly available in
obstetric hospital settings. (34 references) (Author)
20090408-23 Going with the flow – An alternative perspective on VBAC - Birthspirit Midwifery Journal , no 1, February
2009, pp 47-50 Davies L - (2009)
A practice incident triggered renewed reflection on the evidence relating to vaginal birth after Caesarean section (VBAC),
and the option of waterbirth in a tertiary care setting for a subsequent labour and birth. (20 references) (Author)