Waterbirth is an attractive prospect for many women to help reduce the pain of labour and excessive pain medication and to achieve a calm birth. But risks and benefits need to be considered, and obstacles overcome to achieve successful water labour and birth.

In a study on midwives' views on water immersion during labour, almost 90 per cent of the midwives interviewed supported it as an option for pregnant women for pain relief, relaxation and in promoting a positive birthing experience.

The most significant concerns cited by midwives were maternal collapse, difficultly estimating blood loss and postpartum haemorrhage. There were also barriers to offering water immersion during labour, which included a lack of accredited staff, lifting equipment and overcoming negative attitudes.

The midwives also indicated that the ability to facilitate water immersion was hindered by policies and guidelines, which didn't always support a women's informed choice for water labour and birth.

What is waterbirth?

A waterbirth means that at least part of a woman's labour, delivery – or both – occur in a birthing pool filled with warm water. A woman can elect to have a water birth in a hospital setting, a birthing centre or at home as part of home birth.

What are the benefits of water birth?

As well as promoting a calm birth, water immersion in a bath or pool during the first stage of labour has been shown to decrease the need for pain medication and make the labour a more enjoyable experience.1

A water birth experience

Mother of three, Mabble Munyimani, chose a water birth for her first child to avoid excessive pain management and a caesarean section.

Ms Munyimani entered the water in the last stage of labour, using gas as pain relief in the earlier stages.

"Water was effective pain management in labour, even in the last stages of labour when pain is very high.

"As I entered the water, and started moving around in the pool, the bouncy of the water was relieving.

"There was a lot of pressure caused by the contractions and water provided the soothing and cooling effect.

"Not long after the I had been in the water, the midwife said I was ready to push so I believe the water did speed up things up.

"Throughout the time in the pool, the midwife closely monitored the baby and me.

"I was allowed to move freely in the pool. There is plenty of room to move around, water is warm, like room temperature, it was like I was going for a swim.

"I felt that I was in control of the situation and the pain was manageable - probably because I had the freedom to move around the water. It made me feel light and buoyant. It was like I was floating.

"I felt I had more control over what was happening, and I pushed the baby out with less invasive support from a midwife.

"I feel the buoyancy of the water makes labour easier, and friction from baby pushing is reduced and somehow eases the baby's transition out."

Tips on preparing for a waterbirth

Drawing on her own positive experience, Ms Munyimani offers the following advice for preparing for a successful water birth.

• Get as much information as possible from your midwife so you can make an informed decision.

• If it's your choice, make sure it is in your birthing plan, so all carers are aware when labour starts.

• Be as open-minded as possible if your birth plan has to change due to unforeseen circumstances that may arise.

A midwife on delivering a positive waterbirth

Kathy Fray, a senior midwife who has performed many waterbirths, says there are often misunderstandings around this birth choice.

"To begin with, fundamentally, there are three stages of childbirth potentially involved in the process:

1. Labouring in warm water to assist with managing the contraction pain of cervical dilatation
2. Birthing the baby under-water
3. Birthing the placenta while still in the birthing-pool

"And not every woman, at the time, feels like she wants to do all three - and not every woman should.

"Also, many women expect that birthing their baby will be a stronger pain than their labour contractions during dilatation, but for most, it's not the case."

Not every woman will be a candidate for waterbirth, but under the right circumstances, there's no reason why women can't use water immersion as part of their birth plan.

"For a healthy normal woman with a healthy normal baby on board, who has established spontaneously into active labour, there should be no reason she can't spend some of her labour being soothed by water."

However, there are benefits to deferring water immersion until the later, more active stages of labour, according to Ms Fray.

"I've found that deferring getting into the pool until at least seven centimetres dilatated can be a greatly beneficial strategy because it 'takes the edge off' as she enters the transition.

"Research has also shown that getting into the water too early can water-log the cervix, and slow down dilatation."

There is mostly little disagreement amongst health professionals that there is any harm in labouring in water, said Ms Fray, but controversy occurs when women choose to birth their baby underwater.

"Midwives experienced with waterbirths are comfortable assisting their clients to achieve this, but few medicalised obstetricians have ever personally routinely assisted at waterbirths. So [they] don't really have much of a qualified opinion - in my opinion - or they are an unusually holistic obstetrician who is supportive of the idea.

"Most Special Care Baby Unit and Neonatal Intensive Care Unit paediatricians loathe waterbirths because they manage the care of the occasional newborn who has accidentally inhaled water during their birth and has respiratory distress requiring admittance for a few hours or even a few days."

There are circumstances where it is advisable to give birth out of the water, explained Ms Fray, such as when a baby measures large or if a woman is at risk of haemorrhaging.

"Getting out of the pool to give birth once some peeps of the head are seen - especially if the baby measures generous for its size – is sensible. As dealing with shoulder dystocia with the woman and baby both underwater is far from ideal!

"Also because of the impossibility to accurately gauge blood-loss in a pool, any woman at risk of haemorrhaging, such as those with iron-deficiency anaemia or low platelets, ideally should birth her placenta on terra firma. Then her estimated blood-loss can be properly monitored and managed to avoid her body unnecessarily going into shock."