Hi, everyone. In today’s video, we’re going to talk about water immersion during labor and birth for pain relief. My name’s Rebecca Dekker, and I’m a nurse with my PhD and the founder of Evidence Based Birth. In today’s video, we’re going to continue our pain management series by talking about the effects of water immersion on pain during labor and childbirth.

Definitions

First, I want to help define some terms for you. During water immersion during labor, a person gets into a tub or pool of warm water before the baby is born. In a waterbirth, the person remains in the water during the actual birth of the baby, and the baby is brought to the surface of the water right after the birth.

The word hydrotherapy is sometimes used to describe the use of water immersion during labor and birth. Hydrotherapy is a commonly used comfort measure that’s used across many different clinical specialties. For example, it can be used to soothe aching or sore muscles or joints, and it can be used for comfort when you’re having cramps with your period or just in general for self-care, such as a warm bath at the end of a stressful day. In this video, we’re going to talk about the use of warm water in labor and birth.

How common is water immersion during labor?

In the Listening to Mothers survey that was published in 2013, researchers looked at people who gave birth in US hospitals across the years 2011 and 2012. They found that 8% of people reported getting into a warm tub of water at any point during labor for pain relief, and 10% described using a hot shower during labor for pain relief.

A previous Listening to Mothers survey found that 49% of people who used a warm bath during labor described it as “very helpful” for pain relief, and 32% of people who used a shower during labor described that as “very helpful”. In contrast, only 24% of people who were given opioids through their IV – these are morphine-like drugs – only 24% said that those were “very helpful”. Although hydrotherapy was reported as being more helpful to mothers than opioids, only 6% of mothers in that study used water immersion in a tub or pool, while 30% had opioids given to them. In general, the use of warm water during labor is underused and has been for quite some time.

Evidence on water immersion during labor for pain relief from randomized, controlled trials

In a meta-analysis, researchers combine the results from different studies to get stronger evidence. In 2009, Cochrane researchers combined evidence from 11 different randomized, controlled trials on water immersion during labor. They found that people who used water immersion during labor were less likely to need epidurals or spinals for pain relief.

A recent review conducted by Shaw-Battista in 2017 looked at seven randomized trials with more than 2,600 participants who used water immersion during labor before they had a regular land birth. These were not water births. Six of the seven trials looked at the effects of water immersion during labor on pain relief. They all found that water immersion provided effective pain management during labor. One trial also found that water immersion reduced anxiety in the mother during labor, and that it only took about 15 minutes of being in a tub of warm water for that decrease in anxiety to happen.

Another trial looked at comments that mothers made in a survey after the birth. They found that water immersion during labor really increased the mother’s satisfaction, especially how they were satisfied with privacy and ability to move around. The words most frequently linked with water immersion during labor were “pain relief” and “relaxation”.

Evidence on waterbirth for pain relief from randomized, controlled trials

If you want to go on and not only immerse yourself in a tub during labor but also have the actual birth in the tub – including the pushing phase and where the baby actually comes out – there is evidence to support waterbirth as a reasonable choice for healthy people with uncomplicated pregnancies.

We recently had two randomized controlled trials published on waterbirth itself. The largest randomized, controlled trial on waterbirth was published in 2013. This study took place in Iran, and there were 100 people in the waterbirth group and 100 people in the land birth group. In the end, 83 people ended up staying in the water to give birth and 88 people gave birth on land. The study was published in Persian, but we were able to get some details thanks to our volunteer translators. The researchers found that people in the water birth group reported less pain, but they didn’t give any details on how pain was measured.

In 2015, researchers from China randomly assigned 60 people to waterbirth and 60 people to land birth. Everybody gave birth in their assigned groups. In this study, just like the previous one, the waterbirth group had lower pain scores. Only 3% of people in the waterbirth group were rated as having Degree III pain, which they described as “moderate pain and an inability to cooperate with the doctor”, versus 23% of people in the land birth group had Degree III pain.

Evidence on waterbirth for pain relief from observational studies

We also have a lot of evidence from observational studies on waterbirth, where they look at people who give birth in the water and record what happened.

In a systematic review conducted by Nutter et al. in 2014, they found that people who used waterbirth were less likely to use pain medication compared to people who gave birth on land. They also reported that mothers were more satisfied with their pain relief after a waterbirth compared to a land birth.

Large Eberhard (2005) study

One of the most detailed studies looking at waterbirth was conducted by Eberhard in 2005. They followed roughly 3,000 people who had a waterbirth, 3,000 people who had a land birth in a bed, and about 1,400 people who gave birth on a special birthing stool on land. The researchers found that when they measured overall pain intensity across all three stages of labor, it did not differ between the three groups. However, the people who chose bed births on land perceived more pain in the first stage of labor, which led to them receiving more medications for pain. People who chose to give birth in the water or to give birth on a special birthing stool were more likely to get through labor without using any pain medication. Because the pain levels were high in all three groups, the researchers proposed that water immersion during labor and waterbirth relieves pain in just as poor a manner as morphine-type drugs, because those were the medications most commonly used in the other groups. People giving birth in bed were also permitted to have epidurals.

The researchers found that the waterbirth group had more perceived pain during the pushing phase, probably because they didn’t have an epidural like they did in the land birth group. This is when they were asking people actually during the pushing phase, “What is your pain right now?”But then they did something really interesting. They asked them during the birth and then also after the birth.

Recall of pain after the birth

During the birth, the people having waterbirths perceived more pain than the people in bed (some of whom had epidurals), but after the birth, in a postpartum survey, the women who had waterbirths recalled less pain. Researchers think that water immersion may alter your perceptions so that after the birth, you have almost like an altered memory of the experience- a more positive memory and a less painful memory. This could explain why in many other different research studies, women have generally used very positive words to describe having a waterbirth.

What if people had the option of water immersion during labor?

Remember we talked earlier about how water immersion during labor and birth is an underused pain relief option? In one interesting study, they looked at how many people chose to use water when it was an option for them. This was a study led by Vanderlaan in the Northwestern United States. They looked back at the medical records of 327 people who did have the option of having water immersion during labor, meaning that the tub was available to them. Of these, 82% actually did choose to use water immersion, so it was a very popular choice. Out of the mothers who initiated the hydrotherapy in the tub, only 9% left the tub for more pain relief with medications. The average time spent in the tub was about two and a half hours, and about half of the mothers who chose to use the tub also chose to give birth in the water. Also, they found that more than 70% of people who were having labor inductions were able to use the tub as well.

Self-hypnosis combined with water immersion during labor

Another interesting study looked at the effects of combining self-hypnosis with water immersion during labor. I know that hypnobirthing and Hypnobabies® and other methods are popular in the United States and other places. This study found that when water immersion is combined with self-hypnosis that people report being more satisfied with their pain relief on average. It seems that those two comfort measures go really hand in hand, using hypnosis or being deeply relaxed and also being in a tub of warm water.

Professional guidelines on water immersion during labor and birth

When it comes to professional organizations’ opinions on water immersion, several professional organizations, including the Royal College of Obstetricians and Gynecologists, the Royal College of Midwives in the United Kingdom, and the American College of Nurse Midwives and the American Association of Birth Centers, all support water immersion during labor and birth for healthy people with uncomplicated pregnancies.

The American Congress of Obstetricians and Gynecologists and the American Academy of Pediatrics recommend that water immersion during labor be offered to healthy people with uncomplicated pregnancies at term. However, they recommend that birth take place on land, not water. Even so, they do state that if you’re pregnant and you have a really strong desire for a waterbirth that you should be allowed to make an informed choice, and that you should be informed that the benefits and risks of this choice have not been studied enough to either support or discourage a request for a waterbirth.

What’s the bottom line?

The bottom line is that researchers have found that water immersion during labor poses no extra risks to the baby. They’ve overwhelmingly found that it lowers the need for pain medications and it makes people feel more satisfied with their pain relief. Hydrotherapy’s effectiveness on pain appears to be less effective than an epidural or spinal, but more effective than using IV opioid drugs. The good thing about water immersion during labor is that there doesn’t seem to be any side effects. Also, evidence shows that water immersion during labor increases people’s satisfaction with their childbirth and their sense of privacy and comfort. Mothers who labor and give birth in water tend to remember their experiences as being more positive and less painful.

That’s it for this video. Feel free to check out the rest of our videos on pain management in this pain management playlist. We also have a YouTube video playlist all about natural induction methods. Thanks everyone. Bye.

To learn more and subscribe to our newsletters for useful information, please visit evidencebasedbirth.com.