Six months after giving birth, a 35-year-old woman said she still felt pain in the region where she received an episiotomy—a surgical incision in the perineum (the region between the vagina and anus) that’s meant to prevent severe tears and aid delivery. Unfortunately, the procedure made using the bathroom feel “like a torture” to her. And the long-term effects of the procedure were not just physical, she told the researchers of a 2020 paper: Her sex life and self-confidence had been permanently changed.
“The psychological shadow might disappear over time, but I don’t know yet,” she said.
Though rates of episiotomies have declined in the U.S. since The American College of Obstetricians and Gynecologists recommended against their routine use in 2006, the procedure is still more common in the U.S. than critics say it ought to be, and remains widespread in other countries. In England, for instance, around one in seven deliveries involve an episiotomy. And a study published last week found that BIPOC patients in the U.S. were more than twice as likely as white patients to be given an episiotomy.
A new analysis of dozens of studies published Tuesday in the journal BMJ Open found an unlikely preventative measure against painful episiotomies: water births.
The term “water birth” describes a range of practices, but all involve immersion in water during some stage of the labor and delivery process. Jennifer Vanderlaan, a maternal health researcher at the University of Nevada, Las Vegas School of Nursing and a co-author of the new paper, said the practice is akin to sitting in a hot tub and is used for pain management.
“It's funny to me that we have to show that, but sitting in a hot tub does reduce pain,” Vanderlaan told The Daily Beast.
The new study analyzed 36 papers published around the world since 2000 and compared a range of outcomes and risks for those giving birth with and without water immersion. Vanderlaan and her team found that a water birth significantly reduced how often pain was reported, as well as the rate of episiotomies—“an intervention which offers no perineal or fetal benefit, can increase postnatal pain, anxiety and impact negatively on a woman’s birth experience,” according to the paper. Additionally, water births decreased the odds of postpartum hemorrhage, opioid injections, and epidurals. However, the study found that a water birth increased the odds of cord avulsion, a complication in which the umbilical cord tears off from the placenta.
Vanderlaan said that an intact perineum goes hand in hand with lower episiotomy rates. For the studies analyzed, water births tended to reduce episiotomies the most in the countries with the highest background rates of the procedure.
“Our hypothesis is that water birth is changing standard practice when it’s being implemented in hospitals, because the way that patients are cared for is different when they're in the water,” Vanderlaan said. Water births may make care providers more present or attentive, and reduce the frequency of procedures that would need to occur out of the tub, like an episiotomy.
Still, not everyone has the knowledge or resources to access a water birth—a practice that seems more common among wealthier folks. A 2021 study of over 46,000 births found that white women from higher socioeconomic backgrounds were more likely than other demographic groups to have a water birth.
Labor is broken down into three stages: dilation of the cervix, birth, and afterbirth (when the placenta is delivered). According to the American College of Obstetricians and Gynecologists, opting for a water birth during the first stage of labor “may be associated with shorter labor and decreased use of spinal and epidural analgesia”; however, their recommendation on the topic notes that further data on the potential risks and benefits of water births during the later stages of labor and delivery are needed.
“Therefore, until such data are available, it is the recommendation of the College that birth occur on land, not in water,” the report reads.
Obtaining these data is not all that straightforward or practical, Vanderlaan said, adding that the guidelines “definitely should be reassessed.” At the very least, this study should put to rest some questions about the risks of a water birth.
“We know it results in fewer episiotomies,” she said. “We have enough evidence to say: yes, this is a safe and effective method of pain control, and it should be made available to women.”
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