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Three Part Question

In [a laboring, uncomplicated pregnant woman who is full term, singleton, and otherwise healthy,] would the [risk of neonatal infections] be increased in [water birth versus bed birth]?

Clinical Scenario

A 34-year-old Caucasian female presents to labor and delivery in active labor. She desires to have a water birth. She is G3P2. She had a bed birth for her first child and a water birth with her second child. During delivery, the water becomes very clouded and dirty. You wonder if the baby has increased risk of infection after contact with this dirty water.

Search Strategy

Medline 1966-present using the OVID interface.
[water birth OR immersion OR labor]. No limits.
Cochrane Database of Systematic Reviews using OVID interface
[immersion] OR [water birth]. No limits.

Search Outcome

17 papers found of which 6 irrelevant and 8 of insufficient quality for inclusion.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Zanetti-Daellenbach R et al 2007 Switzerland	513 patients desiring water birth Delivery in water vs delivery on bed after temporary immersion vs delivery on bed after no immersion	Prospective Observational Study 2b (Etiology/Harm) 1b (Prognosis)	Neonatal infection	No difference except for conjunctivitis between water birth and no immersion groups	Length of study One institution – limited patient sample
Geissbuhler V et al 2000 Switzerland	5484 spontaneous singleton births in cephalic presentation Water birth vs Maia-birthing stool vs Bed birth	Prospective Observational Study 2b (Etiology/Harm) 1b (Prognosis)	Neonatal Infection	No difference	No specific demographic information One institution – limited patient sample No mention of water cleanliness First few days after birth
Thoeni A et al 2005 Italy	Women desiring water birth. Water births, “air” births (bed and stool)	Review Study 2c (Etiology/Harm) 4 (Prognosis)	Neonatal Infection	No difference	Length of study One institution – limited patient sample No demographic data

Comment(s)

There are 2 good prospective observational studies and one rather poor review article. All three demonstrated no difference in neonatal infection rate with water birth - except for conjunctivitis in one study. However, standard protocol in the US is the use of prophylactic antibiotic eye ointment so this would be expected not to be much of concern here.

Clinical Bottom Line

Risk of neonatal infection does not appear to be increased with water birth versus bed birth but more evidence is needed before one can confidently form this conclusion.

References

1. Zanetti-Daellenbach R et al Maternal and neonatal infections and obstetrical outcome in water birth. European Journal of Obstetrics, Gynecology, and Reproductive Biology September 2007; 134(1):37-43
2. Geissbuhler V et al Waterbirths: A comparative study. A prospective study on more than 2,000 waterbirths. Fetal Diagnosis and Therapy 2000; 15(5):291-300
3. Thoeni A et al Review of 1600 water births. Does water birth increase the risk of neonatal infection? The Journal of Maternal-Fetal and Neonatal Medicine 2005: 17:357-361