Expert Committee Throws Cold Water on Immersion Childbirth

Norra MacReady

March 20, 2014

Despite its new-age appeal, childbirth in water has few proven benefits, but multiple risks, and should be approached with caution, according to a committee opinion issued jointly by the American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics.

Research in the field consists largely of "retrospective reviews of a single center experience, observational studies using historical controls, or personal opinions and testimonials, often in publications that are not peer reviewed," the authors write in their article, published online March 20 in Obstetrics and Gynecology and in Pediatrics.

The field is also hampered by a dearth of basic science studies in humans or animals elucidating the mechanisms through which immersion might help. Some studies do not identify which stage of labor is being examined. Many of these problems also plagued the 12 randomized controlled trials covered in a Cochrane review, which involved a total of 3243 women. Other limitations of those studies included small sample size and absence of blinding.

The available data suggest that immersion during the first stage of labor is associated with decreased need for spinal, epidural, or paracervical analgesia compared with controls, as well as a decrease of 32.4 minutes in mean labor duration (95% confidence interval [CI], −58.7 to −6.13 minutes). "However, considering each of these effects (particularly the latter), it is difficult to know how factors other than immersion, such as the structure of care (including health care provid¬ers and timing and frequency of examinations) affected outcome," the authors write. There were no differences in perineal trauma or tears or need for assisted vaginal or cesarean delivery.

As for immersion during the second stage of labor and delivery (the childbirth), 1 of the studies included in the Cochrane review did show an increase in maternal satisfaction, but no other benefits to mother or child have been found. The exact incidence of complications has been hard to determine, but there have been case reports of severe respiratory distress among infants who aspirated the water, including 1 child who died from overwhelming sepsis. Along with the possibility of maternal and fetal infection from ruptured membranes, concerns regarding water birth include the infant's ability to thermoregulate in water, umbilical cord rupture or avulsion, hyponatremia, and perinatal seizures or asphyxia.

"Laboring in water may offer some potential benefits, but delivering underwater does not seem to have clear advantages, and the risk of rare, but serious, consequences to a delivering baby's health is something women and providers should all be aware of," Jeffrey L. Ecker, MD, chair of the ACOG Committee on Obstetric Practice, which developed the opinion, said in a college news release.

Immersion during the first stage of labor may decrease pain and labor duration, although its benefits beyond that are unclear, the committee concludes. Immersion during the second stage has been associated with rare but significant risks and should be considered an experimental procedure that is performed only in the context of a clinical trial, with informed consent.

Facilities that do wish to offer immersion therapy for the first stage "need to establish rigorous protocols for candidate selection, maintenance and cleaning of tubs and immersion pools, infection control procedures, monitoring of mothers and fetuses at appropriate intervals while immersed, and pro¬tocols for moving women from tubs if urgent maternal or fetal concerns develop."

Dr. Ecker and other committee members have disclosed no relevant financial relationships.

Obstet Gynecol. Published online March 20, 2014.

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