Immersion in water during the second stage of labor: a randomized controlled trial


      Current obstetrical guidelines in the United States caution firmly against birth in water, but patients remain interested in this intervention. Limited data are available to evaluate the safety and efficacy of water immersion in the second stage of labor for patients and neonates.


      This study aimed to ascertain the effects of water use during the second stage of labor on maternal outcomes. Second, it aimed to propose guidelines for midwives conducting the second stage of labor in water.


      A randomized, prospective design was used to evaluate the primary outcomes of maternal experience in labor and trauma to the birth canal and several secondary neonatal and maternal outcomes when participants delivered in water vs in a conventional setting. Participants were recruited at 2 academic state hospitals serving the same low- to middle-income group urban population in the midwestern suburbs of Johannesburg, South Africa over a period of 2 years. Individuals in active labor without exclusion criteria were asked to participate in the study. A total of 120 participants were enrolled, with 60 randomized to water birth and 60 to conventional birth. Outcomes were compared using the chi-square and Fisher exact tests.


      The use of water during birth significantly reduced the participants’ perception of experienced pain than what they expected it to be (P=.006) and enhanced their satisfaction with their ability to cope with labor (P=.010). No differences were noted in trauma to the birth canal. No adverse maternal effects were noted. One early neonatal death occurred in the water group. The most likely cause of death was preexisting intrauterine fetal infection.


      Participants who delivered in water were significantly more satisfied with their birthing experience. The possible harmful effect of inhalation of fresh water by a baby is not resolved, and a large randomized controlled trial is recommended. It is recommended that immersion in water during the second stage of labor should only be offered by competent birth attendants who follow specific guidelines until clear evidence is available on the possible beneficial or harmful effects. Pending further evidence, we recommend adding salt to the bath to produce a physiological saline solution to reduce theoretical risks associated with fresh water inhalation by the neonate.

      Key words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to American Journal of Obstetrics & Gynecology MFM
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Cammu H
        • Verlaenen H
        • Amy JJ
        • De Koster K
        • Derde MP
        • Buekens P.
        Epidural analgesia in active management of labor.
        Acta Obstet Gynecol Scand. 1994; 73: 235-239
        • Schorn MN
        • McAllister JL
        • Blanco JD.
        Water immersion and the effect on labor.
        J Nurse Midwifery. 1993; 38: 336-342
        • McCandlish R
        • Renfrew M.
        Immersion in water during labor and birth: the need for evaluation.
        Birth. 1993; 20: 79-85
        • Alderdice F
        • Renfrew M
        • Marchant S
        • et al.
        Labour and birth in water in England and Wales.
        BMJ. 1995; 310: 837
        • Lanier AL
        • Wiegand SL
        • Fennig K
        • Snow EK
        • Maxwell RA
        • McKenna D.
        Neonatal outcomes after delivery in water.
        Obstet Gynecol. 2021; 138: 622-626
        • Johnson P.
        Birth under water–to breathe or not to breathe.
        Br J Obstet Gynaecol. 1996; 103: 202-208
        • Hofmeyr GJ
        • Nikodem VC
        • De Jagert M.
        Birth under water–to breathe or not to breathe.
        Br J Obstet Gynaecol. 1997; 104: 121
        • Sidebottom AC
        • Vacquier M
        • Simon K
        • et al.
        Maternal and neonatal outcomes in hospital-based deliveries with water immersion.
        Obstet Gynecol. 2020; 136: 707-715
      1. Care Quality Commission. Maternity survey 2021. 2021. Available at: Accessed March 17, 2022.

        • Scorah A.
        What You Need to Know about Water Birth.
        the New York Times. The New York Times. 2020 (Available at:) (Accessed March 17, 2022)
        • Cluett ER
        • Burns E
        • Cuthbert A.
        Immersion in water during labour and birth.
        Cochrane Database Syst Rev. 2018; 5CD000111
        • Nikodem VC.
        Immersion in water in pregnancy, labour and birth.
        Cochrane Database Syst Rev. 2000; CD000111
        • Davies R
        • Davis D
        • Pearce M
        • Wong N.
        The effect of waterbirth on neonatal mortality and morbidity: a systematic review and meta-analysis.
        JBI Database System Rev Implement Rep. 2015; 13: 180-231
        • Chaichian S
        • Akhlaghi A
        • Rousta F
        • Safavi M.
        Experience of water birth delivery in Iran.
        Arch Iran Med. 2009; 12: 468-471
        • Ghasemi M
        • Tara F
        • Hami A.
        Comparison between water birth and land birth in terms of fetal and neonatal outcomes.
        Iran J Neonatol IJN. 2014; 5 ([abstract]): 4-5
        • Torkamani SA
        • Kangani F
        • Janani F.
        The effects of delivery in water on duration of delivery and pain compared with normal delivery.
        Pak J Med Sci. 2010; 26: 551-555
        • Gilbert RE
        • Tookey PA.
        Perinatal mortality and morbidity among babies delivered in water: surveillance study and postal survey.
        BMJ. 1999; 319: 483-487
        • Nutter E
        • Shaw-Battista J
        • Marowitz A.
        Waterbirth fundamentals for clinicians.
        J Midwifery Womens Health. 2014; 59: 350-354
        • Vidiri A
        • Zaami S
        • Straface G
        • et al.
        Waterbirth: current knowledge and medico-legal issues.
        Acta Biomed. 2022; 93e2022077
        • Woodward J
        • Kelly SM.
        A pilot study for a randomised controlled trial of waterbirth versus land birth.
        BJOG. 2004; 111: 537-545
        • Wu CJ
        • Chung UL.
        The decision-making experience of mothers selecting waterbirth.
        J Nurs Res. 2003; 11: 261-268
        • Bovbjerg ML
        • Cheyney M
        • Caughey AB.
        Maternal and neonatal outcomes following waterbirth: a cohort study of 17 530 waterbirths and 17 530 propensity score-matched land births.
        BJOG. 2022; 129: 950-958