Mothers and Midwives Archives - Active Birth Pools

Water Birth Pool Safety Risks: What Hospitals Should Avoid Before Buying

Posted on 26 June 202628 June 2026 by K.D.Brainin

Purchasing a water birth pool is a significant responsibility.

The decision should never be based on appearance, price or catalogue features alone.

In a maternity unit, a birth pool becomes part of the clinical environment, the cleaning regime, the hot and cold water system, and the manual-handling strategy.

Every fitting, outlet, seal, drain, hose and access point can either reduce risk or introduce unnecessary complexity.

Some features look reassuring at first glance.

A rim-mounted tap may appear convenient. A swan-neck spout may look elegant. A door may seem to make access easier. A built-in heating or recirculating system may sound technically advanced.

But in a healthcare setting, the first question should always be: does this feature make the pool safer, easier to clean and easier to manage – or does it create another risk point?

This guide explains the design features hospitals, birth centres, architects, procurement teams and maternity staff should question before specifying a water birth pool.

Why design matters in a maternity setting

Healthcare guidance is clear that infection prevention should be designed into healthcare environments from the beginning. HBN 00-09 states that a building’s design can help infection prevention and control by providing an environment that is easy to clean and maintain. [1]

That principle applies directly to water birth pools. A pool with fewer joints, fewer ledges, fewer penetrations and fewer unnecessary fittings is usually easier to clean, inspect, dry and return safely to use. By contrast, complex fittings can create small spaces where moisture, organic matter and microorganisms can remain after cleaning.

NICE recommends that baths and birthing pools are kept clean using a protocol agreed with the local microbiology department or infection-control guidance, and in accordance with the manufacturer’s guidelines. [2] A good pool design should make that requirement practical in a busy maternity unit, not difficult to achieve.

This bath shows a variety of unsafe fittings and systems that are often found on water birth pools.
Note the overflow drain, recirculating water system, swan neck tap, integral shower, rim mounted plumbing and controls.

1. Rim-mounted taps, spouts and showers

Rim-mounted taps, spouts and showers should be treated with caution in a hospital water birth setting.

The issue is not only whether the fitting looks sealed. Bacteria and biofilm are microscopic. Small gaps around a base plate, tap hole, washer or fixing can retain moisture and residue. These areas can be awkward to reach during routine cleaning and inspection.

There is also a water-safety consideration. Water Regs UK notes that all bathroom water fittings need appropriate backflow protection rated to the highest downstream contamination risk, and that showers in healthcare premises can be treated as Fluid Category 5 risk. [3] In a water birth room, the estates team and water-safety group should therefore be closely involved in the specification of taps, showers, hoses, backflow protection and outlet positioning.

Safer principle: keep taps and spouts off the pool rim. Fill the pool from wall-mounted services, an IPS panel or a purpose-designed water column.

This keeps the pool simpler, leaves fewer holes and fittings in the shell, and allows water services to be managed as part of the hospital’s water system rather than as part of the pool itself.

2. Surface-mounted hand grips and internal metalwork

Handholds are important. Mothers need secure support when entering, leaving and changing position in the pool. The question is how that support is provided.

Surface-mounted hand grips, rails and metal plates can introduce fixing points, edges and narrow gaps.

If they sit inside the pool or on the rim, they may come into direct contact with pool water and can make cleaning more complicated.

They can also create protrusions that interfere with movement, comfort and midwife access.

In a clinical setting, cleanability matters as much as strength. A well-designed support feature should feel secure, be easy to wipe, avoid exposed fixings and avoid unnecessary ledges or dirt traps.

Active Birth Pools address this by using integrated, bonded hand grips designed to provide stable support while keeping the internal pool environment smooth, accessible and cleanable.

3. Swan-neck taps and retained water

Swan-neck taps may look attractive, but they are not ideal for a water birth environment.

Their shape can retain water after use, and retained water can contribute to microbial biofilm formation if outlets are not designed, flushed and maintained correctly.

HTM 04-01 gives healthcare premises guidance on the design, maintenance and operation of hot and cold water systems, including control and management of risks from Legionella, Pseudomonas aeruginosa and other waterborne pathogens. [4]

The lesson for birth-pool specification is simple: avoid decorative or domestic-style outlets where a lower-risk, healthcare-appropriate outlet would be easier to manage. Outlet choice should be made with the hospital’s estates, infection-control and water-safety teams.

4. Recirculating, jetted and pumped water systems

Recirculating systems, spa-style jets, pumped heating systems and whirlpool features have no place in a modern hospital water birth pool.

They add pipework, pumps, cavities, valves and hidden wet areas. Once microorganisms enter these systems, they can be difficult to remove. Recirculating or aerating systems can also generate aerosols when bubbles break or water is agitated, increasing the potential route of exposure.

NHS England issued a patient safety alert about heated birthing pools with built-in heaters and recirculation pumps filled in advance of labour. [5] Public Health England later reported that, after a recall of heated home birthing pools, 4 of 6 tested pools were positive for Legionella and 3 also tested positive for other potentially harmful organisms including Pseudomonas aeruginosa. [6]

This does not mean fixed hospital birthing pools are unsafe. The concern is specifically with unnecessary heating, storage, recirculation and hidden systems. The safer approach is to fill the pool for use, monitor water temperature during labour, empty the pool after use and clean it under local protocol and manufacturer guidance.

5. Integral plumbing and hidden services

Integral plumbing systems can look neat, but hidden pipework is rarely an advantage in a healthcare environment.

Flexible hoses, internal pipes, pumps, filters, valves, heaters and concealed spaces can be difficult to inspect, disinfect, maintain and monitor.

Stagnant water in dead legs or rarely used sections of pipework is a recognised water-safety concern. The HSE notes that hot and cold water systems can present a foreseeable risk of exposure to Legionella, and that understanding the water system and its parts – including dead legs, TMVs and outlets – is necessary for risk assessment. [7]

For hospitals, the safer design principle is separation. The birth pool should be a fixed, cleanable sanitary-ware product. The water services should be specified, installed, accessed and maintained by the hospital’s estates team as part of the wider water-safety plan.

6. Handheld showers and hose management

Handheld showers are a common source of confusion. They are useful for cleaning the pool after use, but they can create a risk if the hose or handset can enter the pool water during use.

Water Regs UK explains that shower installations must have appropriate backflow protection and that, in high-risk settings such as healthcare premises, showers may be classed as Fluid Category 5 risk. Hose handsets capable of reaching contaminated water sources require suitable Fluid Category 5 backflow-prevention arrangements unless the hose is permanently restrained or shortened to maintain an adequate gap. [3]

For water birth rooms, the safe approach is to prevent the shower hose or head from entering the pool during labour and birth, and to ensure the design is approved by estates and the water-safety group.

A removable cleaning hose may be acceptable where it is detached when the pool is in use and used only after the pool has been emptied for cleaning, subject to local approval.

7. Built-in filters and disinfection devices

Filters and disinfection devices should not be used to justify a poor basic design.

If a pool relies on filters to compensate for built-in plumbing, recirculation, hidden pipework or complex wet components, the underlying problem remains. Filters require maintenance, monitoring and replacement. They can reduce risk only when they are correctly specified and managed within a formal water-safety system.

The better design principle is to remove avoidable risk at source: no recirculation, no hidden wet systems, no unnecessary pipework inside the pool and no complex internal fittings that are difficult to access.

8. Overflow drains and hidden wet recesses

Overflow drains are another feature borrowed from baths and spa products that should be questioned in water birth pools.

An overflow adds hidden surfaces, internal channels and wet recesses.

These areas can be difficult to access during routine cleaning and can retain moisture between uses. If a feature cannot be reliably cleaned, inspected and dried, it should not be built into a healthcare birth pool unless there is a clear, justified reason.

The safer design principle is a simple, purpose-designed drainage system with components that can be removed, cleaned, disinfected, rinsed, dried and checked in accordance with local policy.

9. Doors, seals and access panels

A door in a water birth pool may appear helpful, but it introduces a major design compromise.

Doors require seals, hinges, locking mechanisms and joints. These features are exposed to warm water, organic matter and repeated cleaning chemicals. Any seal or hinge line can become a moisture trap.

In an emergency, a door may also complicate rather than simplify evacuation, because staff still need space, technique, equipment and coordinated manual handling.

Access should be solved through the pool’s height, internal shape, external step, handholds, midwife access and local emergency procedures – not by introducing a door and seal into the pool shell.

10. Domestic styling in a clinical environment

A maternity pool should not be specified as though it were a domestic bath, spa bath or wellness product.

In hospitals, design priorities are different. The pool must support infection prevention, water-safety governance, manual handling, cleaning, inspection, maintenance and repeated clinical use. A domestic-style feature may look reassuring in a brochure while creating avoidable work for maternity, cleaning and estates teams.

When assessing a pool, procurement teams should ask: Can every surface be reached? Can every component be inspected? Can the pool be cleaned quickly and consistently between births? Are water outlets separate and maintainable? Are there any hidden wet areas? Does each fitting justify its risk?

What safer birth-pool design looks like

A safer water birth pool is not over-engineered. It is simple, strong, cleanable and purpose-designed for maternity use.

Active Birth Pools are designed around this principle. They use smooth Ficore® surfaces, seamless one-piece construction, integrated hand grips, minimal fittings, purpose-designed drainage and water services kept separate from the pool rim. Freestanding installations can be supported by a dedicated water column so that taps, spout, shower and support rail remain separate from the pool itself.

This approach supports the same aim described in healthcare guidance: make the environment easier to clean, easier to maintain and easier to manage safely.

Buyer questions before specifying a water birth pool

Before purchasing a water birth pool, ask the supplier:

Are there any taps, spouts, showers or controls mounted on the pool rim?
Are any hand grips, rails or metal fittings bolted onto the internal surface?
Does the pool include any recirculation, jets, pumps, heaters or hidden pipework?
Can every wet surface be cleaned, disinfected, rinsed, dried and inspected?
Are there any overflows, doors, seals or inaccessible cavities?
Is the pool filled for use and emptied after use, rather than maintained warm in advance?
Has the installation been reviewed by estates, infection-control and water-safety teams?
Does the manufacturer provide clear cleaning and care guidance?

Conclusion: remove avoidable risk at source

No product can replace local clinical judgement, infection-control procedures, estates management or water-safety governance.

But good design can make those responsibilities easier to fulfil.

A hospital water birth pool should not be a spa product adapted for maternity use. It should be a fixed, purpose-designed sanitary-ware product that supports safe water use, effective cleaning, practical midwifery and maternal movement.

The safest features are often the ones that are not there: no rim-mounted taps, no jets, no recirculation, no hidden plumbing, no overflows, no doors and no unnecessary surface-mounted metalwork.

In maternity environments, simplicity is not basic. Simplicity is safer.

Evidence and source notes

[1] NHS England, Health Building Note 00-09: Infection control in the built environment. Summary states that building design can help infection prevention and control by providing an environment that is easy to clean and maintain, and that these features should be designed into a project from the beginning. https://www.england.nhs.uk/publication/infection-control-in-the-built-environment-hbn-00-09/

[2] NICE NG235, Intrapartum care recommendations. NICE recommends offering labour in water for pain relief, monitoring maternal and water temperature hourly, keeping water at or below 37.5°C, and keeping baths and birthing pools clean using agreed infection-control/microbiology protocols and manufacturer guidance. https://www.nice.org.uk/guidance/ng235/chapter/Recommendations

[3] Water Regs UK, What backflow protection is required for a shower? Water fittings in bathrooms require backflow protection appropriate to the highest downstream fluid-category risk; showers in healthcare premises can be Fluid Category 5 risk, and hose handsets require suitable arrangements if they can reach contaminated water sources. https://www.waterregsuk.co.uk/topics/all-faqs/showers/

[4] NHS England, HTM 04-01: Safe water in healthcare premises. Guidance covers legal requirements, design applications, maintenance and operation of hot and cold water supply, storage and distribution systems in healthcare premises, including the control and management of Legionella, Pseudomonas aeruginosa and other waterborne pathogens. https://www.england.nhs.uk/publication/safe-water-in-healthcare-premises-htm-04-01/

[5] NHS England, Patient safety alert: Legionella and heated birthing pools filled in advance of labour in home settings. The alert advised against birthing pools with built-in heaters and recirculation pumps potentially filled in advance of birth. https://www.england.nhs.uk/publication/patient-safety-alert-legionella-and-heated-birthing-pools-filled-in-advance-of-labour-in-home-settings/

[6] Public Health England, Legionella contamination found in more heated birthing pools. PHE reported positive Legionella results in recalled heated birthing pools and reinforced advice against heated, recirculating home birthing pools filled in advance of labour. https://www.gov.uk/government/news/legionella-contamination-found-in-more-heated-birthing-pools

[7] HSE, Hot and cold water systems. HSE notes that hot and cold water systems can present foreseeable risk of exposure to Legionella, and highlights the importance of understanding system components including dead legs, TMVs and outlets. https://www.hse.gov.uk/legionnaires/hot-and-cold.htm

[8] Original Active Birth Pools source page used as the basis for the rewrite: Health and Safety risks you need to be aware of before buying a water birth pool. https://activebirthpools.com/health-and-safety-risks-you-need-to-be-aware-of-before-buying-a-water-birth-pool/

[9] Related Active Birth Pools page used to align house style and avoid duplication: Designed to Optimise Safety, Reduce Risk and Support Safer Birthing Environments. https://activebirthpools.com/birth-pool-safety-design/

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The Rim That Changes Everything

Posted on 15 June 20267 July 2026 by K.D.Brainin

Why Active Birth Pools Support Mothers Like No Other Water Birth Pool

In labour, support matters.

A mother needs freedom to move, but she also needs something dependable to hold, lean on and trust.

She may kneel, squat, turn, rest, rise, lower herself deeper into the water or brace through a contraction.

In water, buoyancy gives her greater freedom.

But that freedom becomes far more powerful when the pool itself supports her wherever she happens to be.

This is where Active Birth Pools are different.

Active Birth Pools are the only water birth pools in the world designed with a continuous, extra-wide, wrap-around bullnose rim.

It is not simply an edge.

It is a complete support system that surrounds the mother, giving her a secure handhold from anywhere in the pool.

The rim supports movement, upright labour, rest, grip, safe transfer, midwifery access and effective cleaning.

It is one design feature that brings together comfort, ergonomics, hygiene and safety.

That is why it is a game changer.

Support From Anywhere in the Pool

Labour is not static.

A position that feels right during one contraction may feel wrong during the next.

A mother may want to lean forward, turn sideways, kneel, sit, squat, rest on her arms or change position completely.

The wrap-around bullnose rim means the mother is never far from support.

Wherever she is in the pool, she can reach the rim, hold firmly, lean into it or use it to stabilise herself as she changes position.

Designed for Upright, Instinctive Labour Positions

Upright, forward-leaning, kneeling and squatting positions are natural to labour and birth.

They allow the mother to follow her instincts, respond to contractions and use the water in a more active way.

The extra-wide bullnose rim makes these positions easier to sustain.

It gives the mother a generous rounded surface to rest her arms, soften her shoulders and lean forward between contractions.

When she needs strength, she can grip the rim.

When she needs rest, she can settle into it.

When she needs to move, the support moves with her because it surrounds the pool.

This combination of warm water, buoyancy and reliable support helps create a calmer, more responsive environment for labour.

The mother is not confined to one part of the pool.

She can explore the space, change position and still have something secure within reach.

That is active birth in practice.

The Extra-Wide Rim Makes the Difference

The bullnose shape is important, but the width of the rim is what transforms it.

A narrow rim may provide an edge to hold, but it does not offer the same comfort for leaning, resting or repeated use during labour.

The extra-wide rim gives the mother a broader, softer and more reassuring surface.

She can rest her forearms on it.

She can lean forward into it.

She can use it for leverage through a contraction.

She can use it to reposition herself without feeling unsupported.

The width also benefits midwives and birth partners.

It gives them a practical surface to rest their arms while remaining close to the mother.

It helps create a more comfortable working and support environment around the pool.

In real birth rooms, these details matter.

Labour can take time.

Support needs to be comfortable, not just available.

A Clear Rim with Recessed Hand Grips

The generous width of the rim also allows the hand grips to be recessed beneath the upper surface.

This is a major design advantage.

The top of the rim remains clear, smooth and comfortable for mothers, midwives and partners.

There are no protruding grips cluttering the surface where the mother may want to rest her arms or lean her body.

When she needs extra leverage, her fingers can naturally find the recessed grips beneath the rim.

The support is there when she needs it, but it does not interrupt the comfort of the upper surface.

Bonded Into Ficore® for Better Hygiene

Ficore® makes this level of integration possible.

Rather than relying on surface-mounted grips with exposed fixings, the hand grips can be bonded into the fabric of the pool itself.

Ficore® also has a greater adhesive factor and is more slip resistant and less slippery than fibreglass or acrylic.

In a wet maternity environment, that material advantage supports confidence for both mothers and staff.

A Safe Transfer Point for Entry, Exit and Evacuation

The extra-wide wrap-around rim also functions as a practical transfer point when mothers enter and leave the pool.

Its generous width gives mothers, midwives and birth partners a stable surface to hold, lean on and use during controlled movement in and out of the water.

This is especially important because entering and leaving a birth pool should feel calm, supported and well managed.

In the event of an emergency evacuation, the continuous rim provides a clear support surface around the pool.

Staff can assist the mother from different positions without relying on awkward reaches, isolated grip points or unsupported lifting.

This supports manual-handling protocols by helping reduce twisting, overreaching and unnecessary strain.

It gives everyone a more secure point of contact and can help reduce the risk of strain or injury for both mothers and midwives.

The rim therefore does more than support labour positions.

It supports safe movement, safe transfer and safer clinical response.

More Than a Rim — A Complete Support System

One of the most important design features of an Active Birth Pool.

The extra-wide bull nose rim is not there to make the pool look different.

It is there to make the pool work better.

For mothers, it means support wherever they are.

For midwives, it means a more practical working environment.

For maternity units, it means a pool designed around comfort, hygiene, manual handling and real clinical use.

The extra-wide is where comfort meets function.

It is where thoughtful design supports the natural physiology of labour.

That is why the rim changes everything.

Must See Video: Freedom of Movement in a Water Birth Pool

Posted on 12 June 202623 June 2026 by K.D.Brainin

This short video shows how an Active Birth Pool gives mothers the space and freedom to move naturally throughout labour and birth.

Warm water allows mothers to explore a wide range of upright, kneeling and supported water birth positions. They instinctively use the shape and internal features of the pool to find positions that feel comfortable, secure and beneficial as labour progresses.

Freedom of movement, together with the relaxing effects of warm water, creates favourable conditions for the release of oxytocin and the natural progression of physiological labour.

The video has now been viewed more than 12 million times on YouTube, demonstrating the worldwide interest in movement, water birth and natural approaches to labour.

How Water Birth Pools Help Mothers Have a Better Experience of Labour and Birth

Posted on 10 June 202623 June 2026 by K.D.Brainin

A comprehensive, evidence-based introduction for parents, midwives and maternity teams

Updated June 2026

For many people, the idea of labouring or giving birth in water still feels unfamiliar. It may sound gentle, even beautiful, but they may wonder: Does it really help? Is it safe? Is it only for certain kinds of birth?

The simple answer is that warm water can be one of the most effective, low-intervention ways to support a woman through labour. A birth pool does not “do” birth for the mother. It gives her an environment in which her body can work more freely, more instinctively and often more comfortably.

Water supports weight. Warmth encourages relaxation. Privacy reduces tension. Buoyancy makes movement easier. Together, these effects can transform the atmosphere of labour from something clinical, exposed and stressful into something calmer, more protected and more mother-led.

This matters because birth is not only a medical event. It is a physical, emotional and hormonal process. The way a woman feels during labour can influence how she moves, how she copes, how safe she feels and how positively she remembers the birth.

What is water immersion in labour?

Water immersion means labouring in a deep bath or birth pool filled with warm water, usually deep enough to cover the mother’s abdomen. The mother may use the pool during the first stage of labour for comfort and pain relief, and she may choose to leave the pool before birth or remain in the water for the baby’s birth, depending on her circumstances, preferences and local clinical guidance.

A “water birth” usually means that the baby is born underwater and then brought gently to the surface. The baby does not breathe underwater; babies are born with protective reflexes, and the first breath normally occurs after the baby reaches air. This is why trained midwifery care, appropriate water temperature, calm handling and safe protocols are essential.

Why warm water helps

The most immediate effect of entering a birth pool is often visible: the mother’s shoulders drop, her breathing slows and her body softens. That relaxation is not incidental. It is central to why water works.

In labour, tension and fear can increase the perception of pain. When a woman feels exposed, watched, restricted or frightened, stress hormones can rise. When she feels private, warm, supported and safe, her body is more likely to produce the hormones that help labour progress, including oxytocin and endorphins.

Warm water helps by creating a quiet boundary around the mother. The pool becomes her space. The water supports her body, reduces the effort required to hold herself upright and allows her to rest between contractions. Many women describe the pool as a place where they can “go inward” and concentrate on the work of labour.

Natural pain relief without loss of control

Water immersion is widely used as a non-pharmacological method of pain relief. It does not numb the body in the way an epidural does. Instead, it helps the mother cope by reducing pressure, easing muscular tension and making it easier to find comfortable positions.

For some mothers, water reduces the need for stronger pharmacological pain relief. Cochrane’s review of water immersion during labour found that labouring in water may reduce the use of epidural or spinal analgesia, without evidence of increased adverse outcomes for mothers or babies in the trials reviewed.

This is important because many women want pain relief but do not necessarily want to lose mobility, sensation or the ability to follow their body’s instincts. Water offers a middle path: meaningful comfort while preserving freedom of movement, upright positions and active participation.

Freedom of movement: why the design of the pool matters

One of the greatest advantages of a birth pool is buoyancy. In water, the body feels lighter. The mother can shift from kneeling to squatting, leaning forward, sitting back or floating with much less effort than on land.

This freedom is not a luxury. It is part of physiological birth. Movement helps the mother respond to contractions, relieve pressure and work with the baby’s descent and rotation. Upright and forward-leaning positions may feel more instinctive than lying on a bed, particularly when the mother is trying to create space in the pelvis.

For this reason, a birth pool should not be thought of simply as a “large bath”. A good birth pool needs to be deep enough, spacious enough and shaped to allow the mother to move freely and to allow midwives to support her safely. The better the pool supports active birth, the more it can help the mother use her own instincts.

Privacy, dignity and the hormonal environment of birth

Birth is intensely personal. Many women labour best when they feel undisturbed, unobserved and secure. A pool can support this by creating a protected physical space. The sides of the pool form a natural boundary. The mother is not lying exposed on a bed. She is upright, covered by water and often more in control of how people approach her.

This sense of privacy can have real physiological value. Labour depends on oxytocin, the hormone that stimulates uterine contractions. Oxytocin flows best in conditions of safety, warmth, trust and low disturbance. A calm, respectful environment can therefore support the natural rhythm of labour.

The psychological benefits are just as important.

A woman who feels in control is more likely to experience birth as something she actively did, rather than something that was done to her. That difference can shape her memory of birth for years.

Shorter labour and fewer interventions?

Research has long suggested that water immersion during the first stage of labour may be associated with reduced use of epidural analgesia and, in some studies, shorter labour. The evidence is not identical across all studies, and outcomes depend on factors such as when the mother enters the pool, her parity, the birth setting and the support she receives.

However, the overall direction of evidence is encouraging: water immersion is a simple, low-cost intervention that can reduce reliance on more invasive forms of pain relief for many women.

When mothers need fewer interventions, maternity teams may also see wider benefits. A woman who remains mobile, comfortable and confident may be less likely to require escalation simply because she is exhausted, distressed or unable to cope.

This does not mean that water prevents complications, nor that every labour in water will be straightforward. It means that water can form part of a supportive environment that protects normal physiology whenever it is safe to do so.

What does current guidance say?

UK guidance has become increasingly supportive of water use in labour and birth. NICE recommends offering women the opportunity to labour in water for pain relief. NICE also now advises that birth in water should be considered, with discussion of the available evidence so women can make informed choices.

The 2025 NICE update is particularly important because it reviewed newer large cohort evidence on water birth during the second stage of labour. NICE concluded that, for low-risk, term, singleton pregnancies, the evidence was reassuring overall: water birth was not associated with increased risk of severe adverse maternal or neonatal outcomes and may offer benefits such as lower risk of postpartum haemorrhage, lower neonatal unit admission and lower severe perineal trauma for multiparous women. NICE also notes a small increased absolute risk of umbilical cord snapping before clamping, so careful practice and informed discussion remain essential.

This balanced message is important: water birth should not be presented as risk-free or suitable for everyone, but neither should it be dismissed as fringe or unsupported. For many healthy women with uncomplicated pregnancies, it is a reasonable, evidence-based option when supported by trained staff and safe facilities.

Is water birth safe for babies?

Parents often ask whether a baby can breathe underwater. During a properly managed water birth, the baby is born into warm water and then brought calmly to the surface. The first breath normally occurs after contact with air.

The key safety requirements are simple but essential: the baby’s head should remain submerged until birth is complete, the baby should be brought gently to the surface without traction on the cord, the water temperature should be monitored, and staff should be trained to recognise when leaving the pool is needed.

Systematic reviews of neonatal outcomes have not found definitive evidence that water birth causes harm compared with land birth, though researchers have repeatedly called for high-quality data and careful protocols. The largest recent UK cohort evidence has been reassuring for women with uncomplicated pregnancies using NHS services.

Who is water birth usually suitable for?

Eligibility varies between hospitals and countries, but water immersion is most commonly offered to women who are healthy, at term, carrying one baby in a head-down position, and expected to have a straightforward vaginal birth.

Some circumstances may mean that labouring or giving birth in water is not advised, or that the mother may be asked to leave the pool. These can include concerns about the baby’s heart rate, significant bleeding, maternal fever, heavy meconium, need for continuous monitoring, complications requiring urgent assessment, or a clinical need for interventions that cannot be safely provided in the pool.

The essential point is that water birth should be supported by clear guidelines, trained midwives, infection control procedures, safe evacuation plans and respectful communication. The mother should always understand that she can choose to leave the pool at any time, and staff may recommend leaving if clinical circumstances change.

Why the experience matters

A positive birth experience is not defined only by mode of birth. It is shaped by whether the mother felt informed, respected, safe, listened to and involved in decisions.

Qualitative research shows that women often associate water immersion with reduced pain, relaxation, privacy, control, autonomy and empowerment. Midwives also identify the importance of adequate resources, training, consistent protocols and a supportive culture.

This is where birth pools can have a profound effect. They change the room. They change the mother’s posture. They change how people approach her. They encourage quiet, patience and observation. They make it easier for birth companions to offer calm support. They remind everyone present that birth is not simply something to manage; it is something to protect.

Benefits for maternity services

For hospitals and birth centres, birth pools are a practical investment in quality of care. They are relatively simple pieces of equipment, but they can have a major impact on the environment of birth.

When used appropriately, water immersion can support:

greater maternal comfort and satisfaction;
reduced use of epidural or spinal analgesia for some women;
more freedom of movement and upright positioning;
privacy and dignity;
lower-intervention care for suitable mothers;
a calmer working environment for midwives;
more efficient use of staff and resources when normal birth is supported safely.

The economic argument should never overshadow the human one. The primary purpose of a birth pool is to improve care. But when better care also reduces unnecessary intervention, improves maternal experience and supports efficient maternity services, the case becomes even stronger.

Conclusion: a simple pool of water with deep benefits

A birth pool is simple, but its effects can be profound.

It offers warmth, buoyancy, privacy and freedom. It helps many mothers relax into labour, cope with contractions, move instinctively and feel more in control. It can reduce reliance on medical pain relief and support a calmer, more physiological birth environment.

For the uninitiated, water birth may seem unusual at first. But when we look at what labour requires — safety, warmth, movement, privacy, skilled support and trust — the logic becomes clear.

Water does not replace midwifery skill. It enhances it. It does not guarantee a particular kind of birth. It creates better conditions for the mother’s body to do what it is designed to do.

For many mothers, that can make the difference between simply getting through labour and experiencing birth as powerful, supported and deeply positive.

References

Cluett ER, Burns E, Cuthbert A. Immersion in water during labour and birth. Cochrane Database of Systematic Reviews. 2018;5:CD000111. doi:10.1002/14651858.CD000111.pub4.
National Institute for Health and Care Excellence. Intrapartum care: NICE guideline NG235. Updated 2025–2026. Recommendations on labouring in water and water birth.
National Institute for Health and Care Excellence. Intrapartum care: Appendix D — Benefits and risks of birth out of water and water birth. 2025 update.
National Institute for Health and Care Excellence. Evidence review Q: Effects and safety of water immersion during the second stage of labour. 2025.
Sanders J, et al. Characteristics, interventions, and outcomes of women who used a birthing pool: the POOL cohort study. 2024/2025.
Burns E, Feeley C, Vanderlaan J, Hall PJ. Systematic review and meta-analysis to examine intrapartum interventions, and maternal and neonatal outcomes following immersion in water during labour and waterbirth. BMJ Open. 2022;12:e056517. doi:10.1136/bmjopen-2021-056517.
Reviriego-Rodrigo E, Ibargoyen-Roteta N, Carreguí-Vilar S, et al. Experiences of water immersion during childbirth: a qualitative thematic synthesis. BMC Pregnancy and Childbirth. 2023;23:395. doi:10.1186/s12884-023-05690-7.
Taylor H, Kleine I, Bewley S, Loucaides E, Sutcliffe A. Neonatal outcomes of waterbirth: a systematic review and meta-analysis. Archives of Disease in Childhood: Fetal and Neonatal Edition. 2016;101(4):F357–F365. doi:10.1136/archdischild-2015-309600.
Vanderlaan J, Hall PJ, Lewitt MJ. Neonatal outcomes with water birth: a systematic review and meta-analysis. Midwifery. 2018;59:27–38. doi:10.1016/j.midw.2017.12.023.
Royal College of Obstetricians and Gynaecologists and Royal College of Midwives. Immersion in Water During Labour and Birth. Joint Statement No. 1. 2006.
American College of Obstetricians and Gynecologists. Immersion in Water During Labor and Delivery. Committee Opinion No. 679. Obstetrics & Gynecology. 2016;128:e231–e236.
Active Birth Pools. The benefits of using water for labour and birth are well known, here are the facts. Blog article, 2019.

Source note

This article has been developed from the Active Birth Pools page “The benefits of using water for labour and birth are well known, here are the facts” and expanded with current evidence and guidance for a broader educational audience.

Active Birth Pools help mothers adopt upright postures to have a better experience of labour and birth

Posted on 9 June 202623 June 2026 by K.D.Brainin

One of the clearest lessons from active birth is that labour works best when the mother is able to respond to her body. Movement, upright posture, rest, support and instinctive changes of position are not extras. They are part of the physiology of labour.

That is why Active Birth Pools are designed to help mothers use upright and forward-leaning positions in water, with the support they need to move freely, conserve energy and remain actively involved in the birth of their baby. [1]

The aim is simple: to create a birth environment that supports natural movement rather than restricting it.

Why upright positions matter

Evidence supports the value of allowing women to adopt positions that feel right to them in labour and birth. Cochrane evidence on positions in the first stage of labour found that upright and mobile positions were associated with a shorter first stage, lower use of epidural analgesia and fewer caesarean births compared with recumbent positions. [2]

Evidence on the second stage is more nuanced. Reviews have found that upright positions may reduce episiotomy and assisted vaginal birth in women without epidural analgesia, while also noting possible trade-offs such as increased second-degree tears or blood loss in some studies. For women with epidural analgesia, the evidence is less clear, and some high-quality trials have not shown the same advantage for upright positions. [3,4]

The practical conclusion is not that one position is best for every mother. It is that women should be encouraged and supported to find the positions that are most comfortable, effective and appropriate for their individual labour. [2,3]

The word upright can include many positions: standing, kneeling, supported squatting, semi-squatting, leaning forward, sitting upright, or moving between these positions as labour progresses.

For birth, squatting and kneeling positions are often described as physiological because they work with gravity and allow the mother to use her body dynamically. However, few women want or need to hold one posture continuously. Labour is rhythmic and changing. A mother may need to lean, rest, float, kneel, turn, hold, release and move again. [3]

This is why good birth pool design should not prescribe a single birth position. It should make many positions easier to use.

Why water makes movement easier

Warm water is widely recognised as an effective form of comfort and pain relief in labour. NICE recommends offering women the opportunity to labour in water for pain relief, and Cochrane evidence suggests that immersion in water during labour may reduce the use of epidural analgesia, without evidence of increased adverse outcomes for mothers or babies in the trials reviewed. [5,6]

Water changes the way the body feels. Through buoyancy, the body is supported by the water it displaces. This can reduce the strain of bearing weight, making it easier for the mother to change position, rest between contractions and explore upright or forward-leaning postures that may feel more difficult on land. [7]

For many mothers, entering the pool can bring a renewed sense of energy, privacy and focus. The water supports the body, while the pool should support movement.

Designed to support active birth

Active Birth Pools are designed around the mother in motion. The recessed handgrips, broad rounded rim, Labour Support Seat, Safety Seat and Lumbar Support are not intended to hold the mother in one position. They are there to give her more choices. [1]

She can hold the recessed handgrips for stability, lean into the wrap-around rim, rest briefly on a support seat, or use the internal features to help her move safely from one position to another. The design allows her to find what works for her body as labour changes. [1]

This matters because a poorly designed pool can restrict the very movement water birth is meant to encourage. If the mother is pushed into a semi-recumbent posture, or if the internal shape limits her ability to turn, kneel or lean forward, the pool may recreate the limitations of a bed-based birth in water.

Birth is a dynamic process. The pelvis, sacrum and soft tissues respond to posture, movement and pressure. Forward-leaning, kneeling and upright positions can help the mother create space and use gravity, while also allowing her to adjust instinctively as the baby descends and rotates. [3]

The role of the pool is to protect that freedom. It should support the mother without fixing her in place. It should make it easier for her to move when she needs to move, and easier to rest when she needs to rest.

This principle is at the heart of Active Birth Pool design.

Helping mothers conserve energy

Many women do not have the stamina to remain upright on land for long periods, especially as labour intensifies. In water, buoyancy reduces physical effort and gives the mother more ways to use upright postures without becoming exhausted. [7]

This is especially important during the later stages of labour, when the mother may need both mobility and rest. A well-designed birth pool can help her alternate between active positions and supported rest, without leaving the water or losing the benefits of warmth and buoyancy.

In this way, water can help mothers remain active for longer, not by demanding more effort, but by reducing unnecessary strain.

Designed for better births

When women are free to move, supported in water and able to follow their instincts, they are more likely to feel involved, confident and in control. This aligns with the World Health Organization’s description of a positive childbirth experience, which includes practical and emotional support, safety, dignity and a sense of personal achievement. [8]

Active Birth Pools are designed to support that experience. They help mothers use the upright and active positions natural to labour, while giving midwives access and giving partners the opportunity to remain close and supportive. [1]

The result is a pool that does more than contain water. It creates a birth environment shaped around movement, comfort, support and choice.

Conclusion

Mothers have better births when they are supported to remain active participants in labour and birth.

That is the purpose behind every Active Birth Pool: to make it easier for mothers to move freely, use upright postures, conserve energy and benefit from the comfort of warm water without being restricted by the pool itself.

Because a birth pool should not tell a mother how to give birth. It should help her listen to her body and do what comes naturally.

References

[1] Active Birth Pools. “The keyword that defines our approach to design is Active.” Active Birth Pools. Accessed 11 June 2026. Source

[2] Lawrence A, Lewis L, Hofmeyr GJ, Styles C. “Maternal positions and mobility during first stage labour.” Cochrane Database of Systematic Reviews 2013, Issue 10. Art. No.: CD003934. DOI: 10.1002/14651858.CD003934.pub4. Source

[3] Gupta JK, Sood A, Hofmeyr GJ, Vogel JP. “Position in the second stage of labour for women without epidural anaesthesia.” Cochrane Database of Systematic Reviews 2017, Issue 5. Art. No.: CD002006. DOI: 10.1002/14651858.CD002006.pub4. Source

[4] Kibuka M, Thornton JG. “Position in the second stage of labour for women with epidural anaesthesia.” Cochrane Database of Systematic Reviews 2018, Issue 11. Art. No.: CD008070. DOI: 10.1002/14651858.CD008070.pub4. Source

[5] NICE. “Intrapartum care: Recommendations.” NICE guideline NG235, recommendation 1.6.10: offer women the opportunity to labour in water for pain relief. Updated/amended 2025. Source

[6] Cluett ER, Burns E, Cuthbert A. “Immersion in water during labour and birth.” Cochrane Database of Systematic Reviews 2018, Issue 5. Art. No.: CD000111. DOI: 10.1002/14651858.CD000111.pub4. Source

[7] Encyclopaedia Britannica. “Archimedes’ principle.” Explains buoyant force and the support created by displaced fluid. Source

[8] World Health Organization. “WHO recommendations: intrapartum care for a positive childbirth experience.” Guideline, 7 February 2018. Source

Why Active Birth Pools Are Especially Beneficial for Larger and Plus-Size Women

Posted on 8 June 202623 June 2026 by K.D.Brainin

There is a subject that maternity planning does not always address openly or often enough.

Many women enter labour carrying more body weight, living with restricted mobility, experiencing pelvic or joint discomfort, or simply finding it difficult to kneel, squat, turn and remain upright for extended periods. This includes women who are described clinically as overweight or obese, women who identify as large or plus size, and women of any size whose movement is limited by pregnancy, pain, disability, fatigue or other physical factors.

These mothers may be among those who stand to gain most from the buoyancy, support and freedom of movement provided by a properly designed water birth pool.

Yet they are also among the women who may be least likely to be offered access to water during labour and birth. Research from England has found that women recorded as obese were less likely to give birth in water.[1] In some maternity services, body mass index thresholds have historically been used to restrict access, even where a woman’s individual circumstances might otherwise allow water immersion to be considered.

This deserves closer examination.

The physical reality of labour on land

Women are commonly encouraged to remain mobile and to adopt upright, forward-leaning, kneeling, side-lying or asymmetrical positions during labour. The World Health Organization recommends encouraging mobility and upright positioning during labour for women at low risk.[2] NICE also advises that upright positions and keeping mobile may be beneficial for women without an epidural during the second stage of labour.[3]

These recommendations are physiologically sound, but they can be difficult to put into practice.

For a larger woman, moving from standing to kneeling, maintaining a supported squat, turning from one side to another or getting up from the floor may require considerable muscular effort. The weight of the abdomen, pressure on the knees and hips, reduced balance, breathlessness and fatigue can all limit the positions that feel achievable.

A woman may understand the value of mobility but still be physically unable to sustain the postures that feel most natural during labour. This is not a failure of motivation. It is an environmental and ergonomic challenge.

A birthing room that offers only a bed, chair, floor mat or standard bath may unintentionally restrict the mother’s choices. When changing position becomes difficult, she may spend longer reclining or lying on the bed, not because this is instinctively right for her, but because other options are uncomfortable, exhausting or inaccessible.

Water can make freedom of movement possible when movement on land is difficult.

Buoyancy changes what the body can do

Immersion in sufficiently deep water changes the physical experience of movement.

Buoyancy partially supports the mother’s body, reducing the load placed on her muscles and weight-bearing joints. Warm water can promote relaxation, ease muscular tension and make it easier to turn, kneel, lean forward, sit, squat or float between positions.

A systematic review and meta-analysis of water immersion during labour found benefits for healthy women and their newborns and associated immersion with reduced use of several intrapartum interventions.[4] Reviews also describe warm water as supporting relaxation, comfort and easier movement between positions.[4,5]

For a woman who finds movement difficult on land, this support may be transformative.

In water, she may be able to:

turn without having to lift her full body weight;
move from sitting to kneeling with less strain;
lean forward while the water supports her abdomen;
widen or adjust her knees and hips more comfortably;
rock or rotate her pelvis during contractions;
adopt asymmetrical positions;
rest while remaining upright and immersed;
change position more frequently without exhausting herself.

The objective is not to prescribe one “correct” birthing position. It is to create an environment in which the mother can explore movement, follow her instincts and find the position that feels right at each stage of labour.

Depth is essential

Not every pool provides the same degree of buoyancy.

For water to support the body effectively, it must be deep enough for meaningful immersion. A shallow bath may provide warmth and some pain relief, but it cannot reproduce the same freedom of movement as a purpose-designed pool with adequate water depth.

Active Birth Pools typically provide a water depth of approximately 640–650 mm when filled to the specified operating level, depending on the model.[6,7] This depth allows the water to support a substantial proportion of the mother’s body when she is kneeling, sitting, squatting or leaning forward.

For larger mothers, adequate depth is particularly important. If the water level is too low, the abdomen, shoulders and upper body remain unsupported and the mother must continue carrying much of her weight through her legs, knees and arms.

The value of a birth pool is therefore not determined simply by whether it holds water. Its internal depth, dimensions, contours and support features determine how effectively the mother can use buoyancy.

Space matters too

A pool can be deep but still restrict movement if it is too narrow, too short or poorly shaped.

Larger women need sufficient internal room to turn, widen their knees, change the direction in which they are facing and move between upright, kneeling, forward-leaning and resting positions. They should not feel enclosed, wedged into one position or concerned about colliding with taps, fittings or protruding accessories.

Active Birth Pools are designed with open internal space and smooth, flowing contours. Different models accommodate different room sizes and clinical requirements, with the larger Active pool offering particularly generous internal dimensions.[6]

The absence of unnecessary obstructions allows the mother to move without continually having to negotiate equipment inside the pool.

This is an important distinction between a purpose-designed water birth pool and a large bath. The aim is not simply to contain the mother. It is to create a supportive environment for active labour.

Support should be available wherever the mother needs it

Buoyancy provides freedom, but mothers also need stable points of support.

During a contraction, a woman may want to pull, brace, lean, grip or rest. These instinctive actions can help her feel secure and in control. They are particularly valuable for women who may be less confident about their balance or who find it difficult to support their body weight without assistance.

Active Birth Pools incorporate features such as:

broad, rounded rims that can be held or leaned upon;
integrated handholds or grab rails, depending on the model;
submerged seats for resting while remaining immersed;
lumbar and body support formed by the pool’s internal contours;
space for forward-leaning and kneeling positions;
stable entry and exit arrangements.

These features allow the mother to use the pool instinctively rather than having to follow complicated instructions.

A submerged seat can provide a place to pause and recover without leaving the water. A well-positioned handhold can help her rotate her pelvis or steady herself as she moves. A curved wall can support her back or shoulders. A broad rim can support forward leaning while allowing her abdomen to remain buoyant.

This combination of freedom and support is central to the Active Birth Pools design philosophy.

Protecting dignity and reducing unnecessary assistance

Larger and less-mobile women can sometimes find themselves surrounded by additional staff whenever they need to change position, get off a bed or move to another part of the room.

Although support should always be available when required, needing several people to assist with basic movement can leave a woman feeling exposed or dependent.

Inside a well-designed pool, buoyancy may enable her to make small and large positional changes herself. The mother can respond to her contractions privately and instinctively, with the midwife nearby rather than physically directing every movement.

NICE now specifically recommends supporting women and pregnant people with mobility issues to access water during labour and birth through individualised needs assessment and reasonable adjustments.[3] This is an important recognition that restricted mobility should not automatically be treated as a reason to withhold water. In some circumstances, it may be one of the strongest reasons to make water accessible.

Health, safety and ergonomics must be designed in

For larger or less-mobile women, a well-designed pool can contribute to this safer system by enabling more self-directed movement and by reducing foreseeable demands on staff to lift, pull, hold or reposition a woman’s body weight. The aim is not “no handling” at any cost. It is to avoid unnecessary handling and to make any assistance that remains necessary planned, proportionate and safer.

An ergonomic approach asks whether the environment is compatible with the capabilities and limitations of the people who use it. In maternity care, this includes the mother, midwives, maternity support workers and any staff who may be needed in an urgent situation. Human-factors guidance emphasises improving safety through system and equipment design, rather than relying only on individuals to compensate for a poorly designed environment.[13]

The Manual Handling Operations Regulations 1992 require employers, so far as is reasonably practicable, to avoid hazardous manual handling, assess operations that cannot be avoided and reduce the risk of injury.[10,11] HSE guidance for health and social care applies this approach to the movement and support of people because poor practice can injure both the person receiving care and the staff assisting them.[12]

Health and safety is not achieved simply by asking staff to use a “good lifting technique”. It begins with the design of the task, the room, the equipment and the care pathway.

Entry and exit must be designed around real women

Access to the pool is not a minor operational detail.

For larger and plus-size mothers, and for women with pain, restricted hip or knee movement, reduced balance or fatigue, the method of entry can determine whether water immersion is genuinely accessible at all.

Why sit and swivel is especially important

Climbing a conventional step unit requires the mother to raise her centre of gravity, transfer her weight from one leg to the other and negotiate the pool wall while turning or stepping down. During labour, these movements may be made while she is tired, wet, contracting or unable to see her feet clearly.

For a larger mother, the demand on the knees, hips, pelvis and supporting leg can be greater, while the consequences of losing balance may affect both her and the staff member trying to steady her.

The Active Birth Pools sit-and-swivel method replaces climbing with a controlled sequence. The mother approaches the pool, uses the low single step where required, sits securely on the extra-wide rim, turns her body while seated, brings her legs into the pool and lowers herself into the water using the rim, recessed handrails and assistance appropriate to her assessed needs.[19,20]

Sitting before turning is the crucial ergonomic difference. Her weight is supported before she crosses the pool wall. She is not required to balance on one leg, step over a high edge or place her body weight through a midwife’s neck, shoulders or arms. The broad rim also gives her time to pause between contractions and complete each part of the movement in a controlled way.

For larger and less-mobile mothers, sit and swivel can:

reduce the need to climb while wet, tired or contracting;
avoid a high single-leg step over the pool wall;
lower the mother’s centre of gravity before she turns;
allow movement to be divided into small, controlled stages;
provide a stable seated pause if a contraction begins;
reduce the likelihood that the mother will pull heavily on a midwife for support;
allow assistance to be planned around the individual rather than improvised;
support dignity by enabling the mother to do as much of the movement as she can herself.

This is particularly important because HSE identifies active support during entry and exit, the mother’s position and the working posture of staff as sources of manual-handling risk around birthing pools.[12,20] A pool should therefore be judged not only by how comfortable it is once the mother is immersed, but by how safely and naturally she can cross its boundary.

Emergency evacuation must be anticipated in the pool design

Emergency evacuation from a birth pool is uncommon, but it must be treated as a foreseeable clinical and manual-handling task. NHS water-birth guidance commonly requires staff to know and rehearse the local evacuation procedure, and some policies specify staffing arrangements, evacuation equipment or drills.[21-23]

The safest response is not created at the moment an emergency occurs. It is created earlier through pool selection, room planning, equipment compatibility, staffing, training and rehearsal. A design that gives several practical evacuation options is safer than one that leaves the team dependent on a single difficult manoeuvre.

Active Birth Pools are designed around this reality. Their broad rim, rim-level safety seat, recessed handrails, open internal space and accessible pool perimeter can support a staged evacuation and give staff practical choices according to the mother’s condition.[20,24] The pool can also accommodate an appropriate portable hoist where the organisation’s risk assessment and procedure require one.[24]

Design features that support emergency evacuation include:

a rim-level safety seat that provides an intermediate supported position close to the top of the pool;
a broad, strong rim that can be approached from outside and used during a controlled transfer;
recessed handrails and support points that do not obstruct the mother or evacuation equipment;
generous internal space so staff can reposition the mother and place a sling or evacuation aid;
an uncluttered water space without protruding fittings that impede movement;
external access for staff, a bed or trolley and, where specified, a portable hoist;
a pool and room layout that allows the agreed transfer route to be practised rather than assumed.

These features are especially significant for a larger mother because an improvised manual lift carries greater potential risk to her and to staff. However, emergency-friendly design is safer for everyone. A woman of any size may become faint, exhausted, unresponsive or suddenly unable to assist. The relevant safety question is not whether staff believe they could lift a particular mother; it is whether the complete system allows the team to evacuate any mother using a planned, practised and risk-assessed method.

Better for larger women – beneficial for every woman

The design features that can make water especially valuable for larger or less-mobile women also benefit women of every shape, size and level of mobility.

A woman who is highly mobile on land can use the pool to move even more fluidly between positions. She can kneel, squat, lunge, lean forward, rotate her pelvis or float during periods of rest. The resistance of the water allows movements to be slower and more controlled, while buoyancy reduces the muscular effort required to sustain them.

A woman of average size may find that a posture she could hold for only a few minutes on land can be maintained comfortably for much longer in water.

A tired woman may rediscover movement after entering the pool. A woman experiencing pelvic discomfort may find that water allows her to open or reposition her legs more comfortably. A woman who feels vulnerable or observed may experience the pool as a private, protected space.

Inclusive design does not provide a special facility for one category of woman at the expense of another. It creates a better environment for everyone.

When a pool is deep enough for a large woman, it provides effective immersion for a smaller woman. When it is spacious enough for a woman with restricted movement to turn comfortably, it gives a more mobile woman freedom to explore a wider range of positions. When the supports are strong and well positioned, every mother can use them instinctively.

The pool itself makes a difference

Simply offering “access to water” is not enough. The design of the pool determines whether that access is meaningful.

An appropriate water birth pool should provide:

sufficient depth for effective buoyancy;
enough internal space for unrestricted movement;
stable support for upright and forward-leaning postures;
comfortable places to rest while remaining immersed;
secure and dignified entry and exit;
surfaces that support traction;
good access for midwives;
compatibility with local emergency and manual-handling procedures.

From a health-and-safety perspective, generous working space, unobstructed internal contours, accessible support points and a controlled sit-and-swivel entry method are not merely comfort features. They are ergonomic features that can reduce avoidable physical demands on the mother and the staff caring for her. Local risk assessment must still consider the complete installation, staffing model, evacuation plan and any auxiliary equipment.

Active Birth Pools have been developed specifically around these requirements. They are hospital sanitary products designed for professional maternity environments – not medical devices and not enlarged domestic baths.

Their purpose is to give mothers the space, depth, comfort and support required to remain active in water, while enabling midwives to observe and care for them effectively.

A more inclusive approach to water birth

Larger and plus-size women should not be made to feel that physiological labour, active birth or water immersion belong only to smaller, highly mobile bodies.

For some women, the benefits of water are pleasant and comforting.

For others, buoyancy may be the factor that makes upright movement, pelvic mobility and positional choice physically possible.

Maternity services should recognise this distinction. Instead of asking whether a larger woman fits a conventional model of water-birth eligibility, they should consider whether the right pool, room, assessment and support plan can meet her individual needs.

A well-designed Active Birth Pool gives larger and less-mobile mothers a better opportunity to experience comfort, autonomy, freedom of movement and the postures that may support physiological labour.

References

Aughey, H. et al. (2021). Waterbirth: a national retrospective cohort study of factors associated with its use among women in England. BMC Pregnancy and Childbirth, 21, 256.
World Health Organization (2018). WHO recommendations: Intrapartum care for a positive childbirth experience. Recommendation 25: maternal mobility and position.
National Institute for Health and Care Excellence (2025). Intrapartum care, NICE guideline NG235. Recommendations 1.6.13 and 1.9.5-1.9.6.
Burns, E. et al. (2022). Systematic review and meta-analysis to examine intrapartum interventions and maternal and neonatal outcomes following immersion in water during labour and waterbirth. BMJ Open, 12, e056517.
Mellado-García, E. et al. (2024). Water immersion during labour and birth: systematic reviews and synthesis without meta-analysis. Healthcare, 12.
Active Birth Pools. Active II/360 Birth Pool: Technical Specifications. Water depth approximately 640 mm at the stated filling level.
Active Birth Pools. Venus II and Venus 360 Birth Pools: Technical Specifications. Water depth approximately 640-650 mm at the stated filling level.
Royal College of Obstetricians and Gynaecologists (2018). Care of Women with Obesity in Pregnancy, Green-top Guideline No. 72.
Active Birth Pools. Material Specification: Ficore®. Comparative material characteristics, including traction and performance relative to acrylic and fibreglass.
Great Britain (1992). Manual Handling Operations Regulations 1992, SI 1992/2793, regulation 4 and Schedule 1.
Health and Safety Executive (2025). Manual Handling Operations Regulations 1992: Guidance on Regulations, L23. Guidance on avoiding, assessing and reducing manual-handling risk.
Health and Safety Executive (2026). Moving and handling in health and social care. Guidance on preventing injury to people receiving care and to workers.
Chartered Institute of Ergonomics & Human Factors. Healthcare Sector and What is Ergonomics? Guidance on designing healthcare systems around human capabilities, safety and wellbeing.
Health and Safety Executive (2025). Assess manual handling you cannot avoid. Guidance on task, load/person, working environment and individual capability, including awkward postures, reaching and twisting.
Health and Safety Executive (2026). Getting help with manual handling risks in your business. Guidance noting that general lifting-technique training alone is not an effective substitute for changing work and controlling risk.
Great Britain (1998). Lifting Operations and Lifting Equipment Regulations 1998, SI 1998/2307.
Health and Safety Executive (2026). Moving and handling equipment in health and social care. Guidance on selection, use, inspection and examination of equipment used to move or lift people.
Health and Safety Executive (2025). Safe use of lifting equipment: Lifting Operations and Lifting Equipment Regulations 1998. Approved Code of Practice and guidance, L113.

Sit and Swivel – the Safe Way to Enter a Water Birth Pool

Posted on 5 June 202623 June 2026 by K.D.Brainin

All women no matter what their shape or size will find it exceptionally easy to get into our water birth pools. Mothers don’t even think about it – they move instinctively and naturally lower themselves into the water.

Why safe access begins with the design of the pool itself

Entering a water birth pool should feel simple, instinctive and secure – never like an obstacle course. For a mother in strong labour, who may be tired or less steady on her feet, the safest access method is one that reduces climbing, preserves balance and minimises the need for physical assistance.[1-4]

The Active Birth Pools solution

A compact 15 cm single step and an extra-wide, rounded rim allow the mother to step up, sit down, swivel her legs into the pool and lower herself gently into the water. The movement is grounded, controlled and familiar, with three points of contact maintained through the transfer.[1,2]

A simple movement – designed into the pool

The simple act of entering a birth pool is one of the most misunderstood aspects of water birth practice. It should never create anxiety, require awkward manoeuvres or expose the mother or midwife to avoidable risk.[1,2]

Active Birth Pools were developed with manual handling, ergonomics and safe access in mind. The design was considered with safety and manual handling expertise so that women of different shapes, sizes and fitness levels can enter with ease and with minimal need for assistance.[1,2]

Mothers do not need to climb over the pool. They sit, swivel and lower themselves into the water in one natural, fluid sequence.

How the sit-and-swivel method works

1. Step onto the compact single step. The 15 cm height advantage lowers the effective rim height of a typical 75 cm Active Birth Pool to approximately 60 cm – comparable with an ordinary bath.

2. Turn and sit securely on the broad rim. The extra-wide, rounded rim provides a comfortable, supportive surface rather than a narrow edge.

3. Swivel the legs into the water. The mother remains seated and grounded while moving her legs over the rim.

4. Lower gently into the pool. The movement can be paused and controlled, including if a contraction occurs during entry.[1,2]

Because the mother can maintain three points of contact, the transfer is more stable and less dependent on precise balance than climbing a multi-step unit, standing at height, stepping over a rim and descending into water.[2]

Why the single step makes such a difference

The single step is not intended to create a staircase. Its purpose is simply to reduce the effective height of the pool rim before the mother sits down. Used together with the wide rim, it supports a grounded transition into the water without requiring the mother to climb.[1,2]

• The average Active Birth Pool height is approximately 75 cm – similar to a desk or dining table.

• The 15 cm single step reduces the effective entry height to approximately 60 cm – similar to an ordinary bath.

• The compact step does not dominate the poolside or prevent the midwife from moving freely around the pool.

• Its small footprint helps preserve a clear working area and reduces obstruction and trip risk.[1,2]

Protecting mothers and safeguarding midwives

HSE guidance identifies manual handling risks where staff actively support a mother’s entry or exit, or where the mother uses the midwife as a support. HSE also advises that hazardous manual handling should be avoided where reasonably practicable and that unavoidable risks should be assessed and reduced.[3-6]

The sit-and-swivel method addresses the issue at source. By replacing a climb-and-step-over sequence with a seated transfer, it reduces the likelihood that a midwife will need to steady, lift, catch or become a handhold for a mother who is tired, contracting or unsteady.[2,3]

This matters because an unexpected loss of balance can place a sudden and unpredictable load through a midwife’s back, shoulder or arm. Good pool design should minimise that foreseeable people-handling risk rather than relying on staff strength or reaction.[2,3,6]

Why multi-step entry systems deserve careful scrutiny

There is a widespread assumption that a large step unit with handrails must be the safest way to enter and leave a birth pool. In practice, such systems are often required because the pool has a narrow rim or a high, straight-sided profile that cannot support a seated transfer.[1,2,7-9]

A multi-step system may look reassuring, but the whole movement sequence should be considered. A mother may need to climb, turn or reposition, step over the rim and descend into water – potentially finding a submerged floor, seat or plinth while her balance, concentration and coordination are affected by strong labour.[2]

The movement pathway: a practical comparison

Consideration	Sit and swivel	Multi-step entry
Climbing	No multi-step climb	Climbing required
Position while crossing rim	Seated and grounded	May be standing or elevated
Three points of contact	Maintained naturally	Variable through the sequence
Need for physical support	Reduced	Potentially increased
Poolside obstruction	Minimal	Larger footprint
Trip risk when not in use	Low	May be greater
Cleaning, movement and storage	Lower burden	Additional handling and storage task
Emergency access around pool	Clearer perimeter	Potential obstruction

Source: Active Birth Pools Manual Handling Assessment; HSE guidance.[2-6]

Wet-room conditions change the risk

A birth room containing a pool is a wet clinical environment. Even with careful housekeeping, the mother may have wet feet and water may be present around the access point. Strong labour can also alter movement: a mother may pause suddenly, close her eyes, grip, squat, lean or become temporarily unable to follow a sequence of instructions.[2,10]

An access method should therefore allow her to stop safely. With sit-and-swivel entry, she can pause while seated on the rim. The risk is different if a contraction begins while she is part-way up a step unit or standing as she negotiates the pool edge.[2]

Clear space around the pool matters

A bulky step unit does not disappear after entry. If left beside the pool, it occupies working space in the area where midwives, partners and equipment need to move. If moved away, it creates another lifting, cleaning, drying and storage task.[2,7]

The compact Active Birth Pools step provides the required height advantage without obstructing the midwife’s free movement. This helps keep the poolside clearer for observation, support and emergency access.[1,2]

A warning about multi-step systems

The original Active Birth Pools article records the judgement of consulted health and safety specialists in strong terms: “The thought of wet-room conditions with mothers in strong labour climbing up a multi-step unit, stepping over a rim and down onto a submerged plinth is abhorrent.”

It also notes their concern that, when not in use, bulky step units take up space, obstruct movement around the pool and may present a trip hazard.[1,2]

The design principle is straightforward

A handrail may provide a point to hold, but it does not remove the hazards created by climbing, changing direction, stepping over a rim and descending into water. Active Birth Pools solve the access problem at design level: the broad rim is an integral, load-bearing support surface, not an accessory added to compensate for a narrow edge.[2,7-9]

The safest access strategy is not the one with the most equipment. It is the one that removes the unnecessary movement.

Questions for maternity teams and procurement leads

• Can the mother sit safely and comfortably on the pool rim?

• Is the rim wide and rounded enough to support sit-and-swivel entry?

• Does the pool design eliminate the need for climbing?

• Will the access equipment obstruct staff movement around the pool?

• Where will the step unit be placed or stored when it is not in use?

• Does the system add a trip, cleaning or manual handling burden?

• Can midwives work close to the mother without leaning, twisting or reaching?

• Is emergency access around the pool kept clear?[2-6]

Conclusion

Entering a water birth pool should be easy enough that the mother barely needs to think about it. Active Birth Pools’ extra-wide rim and compact single step support an instinctive sequence: step, sit, swivel and lower. The mother remains grounded; the midwife is less likely to become a physical support point; and the space around the pool remains clearer.[1-3]

For mothers in strong labour, for midwives working in a wet clinical environment and for hospitals seeking to reduce manual handling and trip risks, safe access should be designed into the pool from the outset.[2-6]

Supporting document

Manual Handling Assessment: Safe Entry and Exit for Hospital Water Birth Pools

Open the assessment

References

1. Active Birth Pools. Sit and Swivel – the Natural Way to Enter a Water Birth Pool. Accessed 14 June 2026.

2. Active Birth Pools. Manual Handling Assessment: Safe Entry and Exit for Hospital Water Birth Pools. 2026.

3. Health and Safety Executive. Manual handling in birthing pools. Updated 12 January 2026.

4. Health and Safety Executive. Moving and handling in health and social care. Updated 12 January 2026.

5. Health and Safety Executive. Manual handling at work: overview. Updated 25 March 2024.

6. Health and Safety Executive. Manual handling at work: reduce the risk of injury. Updated 1 April 2025.

7. Croyde Medical. Croyde Universal Birth Pool Steps. Accessed 14 June 2026.

8. Febromed. CombiPool. Accessed 14 June 2026.

9. Seagull Medica. Birthing tubs. Accessed 14 June 2026.

10. Milton Keynes University Hospital NHS Foundation Trust. Guideline for the Use of Water During Labour and Birth. 2022.

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Active II Water Birth Pool

Posted on 2 March 202616 July 2026 by K.D.Brainin

The Active II Water Birth Pool is a premium, award-winning water birth pool for hospitals, birth centres and maternity units that want a safe, comfortable and highly supportive pool for physiological labour and water birth.

Designed around the needs of mothers and midwives the Active II combines ergonomic shape, spacious internal proportions, supportive seating, wide working rims and Ficore® composite construction in one seamless, hand-built pool.

Its generous organic form, integrated Labour Support Seat, Rim-level Safety Seat, Recessed Handgrips and Extra-Wide Rounded Rim create a safe, highly supportive environment for mothers, midwives and partners.

Designed for physiological labours and active births

The Active II is a purpose-designed water birth pool shaped around the way women move in labour and the way midwives need to work.

The pool gives mothers the space, depth and support they need to move instinctively, change position and find the postures that feel most comfortable and effective during labour.

The organic internal shape supports upright, kneeling, seated, forward-leaning and resting positions without forcing the mother into one fixed posture.

The result is a calmer, more intuitive birth environment where the mother can use the water, the rim, the seats and the support surfaces naturally.

The Extra-Wide Bullnose Rim

Unique to Active Birth Pools, the extra-wide, wrap-around bullnose rim is one of the most recognisable and purposeful features of our water birth pools.

Rather than functioning simply as the upper edge of the pool, the rim has been designed as a continuous ergonomic support and transfer surface.

Its generous width, softly rounded profile and carefully considered proportions give mothers a comfortable place to hold, lean, brace and rest throughout labour.

From almost anywhere within the pool, the mother can reach the rim and use it to support natural movement and position changes.

She can lean forwards with her arms and shoulders resting on the broad surface, grip the rim during a contraction, turn from one position to another, rise from kneeling, lower herself into the water or prepare to leave the pool with greater confidence.

Support that surrounds the mother

Because the bullnose rim extends around the pool, support is not restricted to one designated area.

The mother can move freely and select the position that feels most comfortable without losing access to a broad, supportive surface.

Whether she is sitting, kneeling, turning, leaning forwards or rising, the rim remains within easy reach.

This continuous support helps preserve the freedom of movement that is central to labouring in water.

A practical working surface for midwives

The extra-wide bullnose rim also has considerable ergonomic value for midwives and birth partners.

Generous open space beneath the projecting rim allows a midwife to sit close to the mother with her legs comfortably positioned beneath the pool edge.

Her arms can rest naturally on the broad rim while she communicates with, observes and supports the mother.

It enables the midwife to remain physically close without having to lean repeatedly over a narrow rim and vertical pool wall.

The rim effectively becomes a comfortable working surface: wide enough to support the forearms, rounded enough to avoid pressure points and positioned to facilitate close, calm communication.

Designed to assist entry and exit

The bullnose rim also acts as a practical transfer point when the mother enters or leaves the pool.

Used with the Active Birth Pools Single Step Unit, it supports a simple and controlled movement sequence:

Step onto the unit. Sit on the wide rim. Swivel towards the water. Lower gently into the pool. For exit, the movement is reversed:

This method avoids requiring the mother to climb over a high pool wall or balance on a large multi-step platform in a wet clinical environment.

The broad rim gives both the mother and attending midwife a stable area around which the movement can be organised, helping to reduce awkward lifting, excessive reaching and avoidable manual-handling strain.

Mid-Level Labour Support Seat

The seat is tilted slightly forward to encourage upright postures and help the pelvis remain open during labour.

It gives the mother somewhere to rest between contractions while continuing to benefit from immersion.

A deep groove through the centre of the seat allows the sacrum to move more freely and helps avoid pressure against the birth canal.

The seat can be used in several ways. The mother may sit upright, turn towards it for support, lean forward over the rim or use it as a resting place while welcoming her baby.

This carefully considered shape distinguishes the Labour Support Seat from a conventional bath seat.

It has been designed around the physical needs of labour and birth rather than simply providing somewhere to sit.

Rim Level Safety Seat

The Safety Seat is a distinctive feature of the Active II.

It provides an additional support platform close to the top of the pool and gives the maternity team practical options for monitoring and emergency evacuations.

The mother may use the seat when changing position, receiving care or preparing to leave the pool.

Its position also allows midwives monitor without requiring the mother to leave the water unnecessarily.

The Active II is compatible with portable hoisting equipment, subject to the maternity unit’s own equipment, procedures, risk assessment and room planning.

The combination of the Safety Seat, open internal space and pool profile supports appropriate emergency-evacuation planning

Recessed Handgrips

The Active II features stainless-steel handgrips set into moulded recesses and bonded directly into the Ficore® pool shell.

Their natural positioning provides firm support for upright, kneeling and forward-leaning positions, helping the mother to brace, turn and change position with greater control and confidence.

Because the grips sit within the rim rather than projecting above it, the broad upper surface remains clear for resting the arms and upper body.

This helps reduce the risk of the mother bumping or injuring herself against raised handgrips, brackets or surface-mounted fittings.

It also minimises snag points and obstructions that could impede access or require awkward reaching by midwives.

The bonded design eliminates exposed brackets, narrow gaps and unnecessary junctions where moisture, residue and microorganisms could remain, creating a smooth, accessible surface that is easier to clean, disinfect and inspect.

The keyhole-shaped water channel: protecting mothers from protruding spouts

One of the Active II’s most innovative features is the keyhole-shaped water channel built into the back of the rim.

By positioning the taps and spout above the water channel and within the pool’s profile, the design helps protect the mother from striking her head or body against protruding plumbing as she leans back, turns, kneels, rises or changes position.

The keyhole shape also opens up the back of the pool, creating more usable space and allowing the mother to move freely and explore positions that are natural to labour and birth.

She can lean comfortably against the back, use the recessed handgrips and rounded rim for support, and reposition herself without being obstructed by the water inlet.

Ficore® composite construction

Active II Water Birth Pools are hand-built to order in England from Ficore®, a solid composite material selected for the demanding requirements of hospital water birth.

Ficore® is exceptionally strong, rigid and durable, providing the structural stability needed for repeated use in busy maternity environments.

Its smooth, warm-to-the-touch surface is comfortable against the body, while its thermal properties help the pool water retain warmth during labour.

Ficore® is resistant to the cleaning and disinfection processes used in maternity settings and, unlike many conventional pool materials, can be professionally repaired and refinished if damaged.

This extends the practical life of the pool, reduces the need for premature replacement and contributes to better lifetime value for hospitals.

Importantly, Ficore® has a greater adhesive factor and is less slippery, or more slip resistant, than fibreglass or acrylic.

Because Ficore® can be moulded into smooth, seamless, one-piece forms, the Active II incorporates fewer joints, crevices and dirt traps than pools assembled from multiple components.

This makes the pool easier to clean, disinfect and inspect, supporting effective infection control practice throughout its working life.

Multi-colour LED lighting and Bluetooth® sound

The Active II can be supplied with integrated multi-colour Chromotherapy LED lighting and a Bluetooth® sound system, helping to create a calmer and more personalised environment for labour and birth.

The lighting can be adjusted to soften the clinical appearance of the room and create an atmosphere that feels more private, reassuring and conducive to relaxation, while still allowing the wider birth-room lighting to be used whenever required.

Bluetooth® connectivity enables women to play music, relaxation tracks, hypnobirthing recordings, guided breathing exercises or other familiar audio from a compatible device.

Together, the lighting and sound options allow the birth-room environment to be adapted to the mother’s individual preferences.

They complement the comfort and freedom of movement provided by the pool, helping create a space in which she can feel more settled, focused and in control throughout labour.

Active II Water Birth Pool

Dimensions: 1965 x 1650 x 770mm
Material: Ficore® composite resin
Lifespan: 25 years +
Guarantee: Lifetime
Lead Time: 4 – 6 weeks + shipping
Availability: Worldwide direct and through selected agents

Download Data Sheet

Request a Quote

Hospital-grade sanitary ware for maternity environments

Active Birth Pools are hospital-grade sanitary ware products designed specifically for maternity environments.

They are manufactured under documented quality-control procedures and designed with reference to applicable sanitary-ware and healthcare-estates guidance, including BS EN 14516 / EN 14516 for cleanability and durability, CEN/TR 17221 for sanitary-appliance Declaration of Performance guidance, and HBN 00-10 Part C for sanitary assemblies in healthcare facilities.

CE documentation and Declarations of Performance are available where applicable. Plumbing and electrical components should always be specified and installed in accordance with local regulatory requirements and the hospital’s estates, infection-prevention and water-safety procedures.

The Keyword that Defines our Approach to Design is ‘Active’.

Posted on 2 April 202511 June 2026 by K.D.Brainin

The keyword that defines our approach to design is ‘Active’.

If we look up the definition of ‘Active Birth’ we get, “Childbirth during which the mother is encouraged to move around freely and assume any position which feels comfortable”.

Founder and Director Keith Brainin spent 17 years as co-director of the Active Birth Centre in London with world famous author, educator and childbirth activist Janet Balaskas where he met water birth pioneer Michel Odent, Sheila Kitzinger and many other midwives and childbirth experts.

The knowledge and understanding gained from this formative experience has enabled us to design water birth pools that uniquely fulfil the needs of labouring women enabling them to have a better experience of labour and birth.

Freedom of movement combined with the relaxing effects of warm water and release of oxytocin significantly increases the possibility of a physiological labour and natural active birth.

We’ve spent decades observing the way that mothers move in our pools and considered how to best serve their needs.

Our passion for excellence has led us to study ergonomic design theory and to work closely with mothers, midwives, health and safety and manual handling experts.

Active Birth Pools provide optimum support for mothers in the range of upright positions natural to labour and birth.

They can hold onto the recessed handgrips or use the wrap around, bullnose-shape rim for support as the they move around the pool to explore and find the most beneficial upright positions.

Features such as the Labour Support Seat, Safety Seat and Lumbar Support create additional possibilities for mothers to explore and find the most comfortable and beneficial positions.

The design of our pools allows partners to sit in comfort and get really close to the mother.

The intimacy that couples experience with our pools is unique. No other pools allow partners to be so close without actually getting in the water.

The support thats provided both physically and emotionally has many benefits, and is key to helping mothers cope with pain and progress to experiencing physiological labour and natural birth.

Mothers simply tell us that, ‘they love our pools’.

They are actively encouraged to move freely and naturally.

They instinctively interact with the pool and find comfort and support wherever they are.

They benefit from complete freedom of movement and unparalleled comfort and therefore have greater probability of experiencing a physiological labour and having a natural active birth.

But, this is not the case with most water birth pools as renown author and educator Sheila Kitzinger OBE wrote in ‘The clock, the bed, the chair’…

“Even a recent innovation, the birth pool, does not always permit free movement.

In theory, a pool allows a woman, supported by water, to move unencumbered.

Or so it might be thought.

Though published research often refers to mobility as an advantage of being in a pool, some pools are elaborate constructions with seats, handgrips and foot-rests, and movement in them is restricted.”

The pool dictates the position the mother should be in by placing her in a semi-recumbent posture with hand holds and foot rests to fix the arms and legs.

Mothers are positioned in the classic lying back with legs wide-open position but happen to be immersed in water.

The seats in these water birth pools are typically tilted backwards.

The mother is immobilised in a position with her pelvis tilted upwards resulting in her pelvic outlet being up to 30% smaller.

This puts pressure on the sacrum which flexes upward, into a curved position that restricts the diameter of the pelvic outlet inhibiting the baby’s descent.

The birth canal is placed in an “uphill” orientation, forcing the mother to push upward against gravity to give birth to her baby.

These seats and moulded fittings greatly reduce the space the mother has to move in and restricts her ability to use the positions most beneficial.

The benefits of labouring in water are largely negated.

The possibility of a physiological labour and natural birth is greatly reduced.”

“Why Privacy, Warmth and Low Light Matter in the Birth Room”

Posted on 21 December 20232 July 2026 by K.D.Brainin

Why the Room Mothers Give Birth in Should Be Like the Room They Made Love in

I first heard this idea from Michel Odent at the Active Birth Centre in London in the late 1980s.

It stayed with me because it made immediate, instinctive sense.

Birth and lovemaking are not the same experience, of course. But they are governed by some of the same deep physiological needs: privacy, safety, warmth, intimacy, low light, freedom from observation, and the ability to let go.

These are not luxuries. They are conditions that help the body work as nature intended.

Birth is affected by the environment

A woman in labour is exquisitely sensitive to her surroundings.

Bright lights, noise, interruptions, unfamiliar equipment, people coming and going, and the feeling of being watched can all disturb the quiet, instinctive state that supports physiological labour.

A calm, private, softly lit room can have the opposite effect. It helps the mother feel safe. It supports relaxation. It encourages the release of the natural hormones involved in labour, birth and bonding. [1,2]

This is why the birth room matters.

It is not simply a clinical space where birth happens. It is part of the birth process itself.

Privacy supports physiology

Michel Odent often spoke about the importance of protecting the labouring woman from unnecessary stimulation.

His central message was simple: when a woman feels private, safe and undisturbed, her body is more able to release oxytocin — the hormone that helps labour progress. When she feels anxious, exposed or scrutinised, stress hormones may rise and the normal rhythm of labour can be disrupted. [1]

This is one reason the comparison with the room where love is made is so powerful.

The ideal birth environment should not feel exposed, institutional or impersonal. It should feel intimate, protected and emotionally safe.

A homely room is not a cosmetic choice

Research into birth environments supports what midwives have long observed: the design of the room can influence how women move, how they feel, and how they experience labour.

Alternative or homelike birth settings have been associated with reduced use of some interventions, increased spontaneous vaginal birth, greater maternal satisfaction, and a more positive experience of care. [3,4]

Good birth room design is therefore not about decoration alone.

It is about creating a space that supports normal physiology, active birth, privacy, dignity and confidence.

The mother needs to move

The bed should not dominate the room.

When the bed is the central feature, it silently suggests that the mother should lie down and become a patient. But in physiological labour, the mother needs freedom to move, lean, kneel, squat, rest, change position and follow her body.

A well-designed birth room should make movement feel natural.

This is one of the reasons water birth pools are so valuable. Warm water gives the mother buoyancy, comfort and freedom. It allows her to change position easily, conserve energy, and remain active without feeling unsupported.

The room, the pool, the lighting, the furniture and the people present should all give the same message:

– You are safe.
– You are private.
– You are free to move.
– Your body knows what to do.

The details matter

A supportive birth environment should include:

• soft, adjustable lighting

• privacy from unnecessary observation

• good acoustic control and reduced noise

• comfortable room temperature

• space for upright and forward-leaning positions

• access to water for labour and birth

• furniture that supports the mother and birth partner

• minimal visual emphasis on clinical equipment

• calm, respectful staff who protect the mother’s space

These features are not decorative extras. They help create the conditions in which physiological birth is more likely to unfold well. [5,6]

The birth room should invite confidence

When a woman enters the birth room, she should not feel that she has entered a theatre, a treatment bay or an emergency setting.

She should feel that she has entered a protected space prepared for one of the most intimate and powerful events of her life.

The room should help her soften, breathe, move, rest, focus inward and trust herself.

In that sense, the room you give birth in really should share something with the room you made love in.

– It should be private.

– It should be warm.

– It should feel safe.

– It should allow instinct to take over.

And it should honour the simple truth that birth, like lovemaking, belongs first to the body.

References

[1] Odent, M. (selected writings and lectures on physiological birth, privacy, oxytocin, dim light and homelike birth environments). See also The Guardian obituary summarising Odent’s work on protecting labour from unnecessary disturbance. https://www.theguardian.com/lifeandstyle/2025/sep/11/michel-odent-obituary

[2] World Health Organization. WHO recommendations: intrapartum care for a positive childbirth experience. Geneva: WHO, 2018. This guideline frames a positive childbirth experience around respectful, woman-centred care, dignity, privacy, emotional support, informed choice and safety. https://www.who.int/publications/i/item/9789241550215

[3] Hodnett, E. D., Downe, S., & Walsh, D. Alternative versus conventional institutional settings for birth. Cochrane Database of Systematic Reviews. The review reports that alternative institutional birth settings are associated with lower rates of some medical interventions and higher maternal satisfaction. https://www.cochrane.org/evidence/CD000012_alternative-versus-conventional-institutional-settings-birth

[4] Goldkuhl, L. et al. Impact of Birthing Room Design on Maternal Childbirth Experience: Results From the Room4Birth Randomized Trial. HERD: Health Environments Research & Design Journal, 2023. The Room4Birth trial found improved self-reported childbirth experience in a specially designed, more person-centred birthing room. https://pubmed.ncbi.nlm.nih.gov/36239523/

[5] Jenkinson, B., Josey, N., & Kruske, S. BirthSpace: An evidence-based guide to birth environment design. Queensland Centre for Mothers & Babies, 2014. The guide reviews evidence on design features that may reduce maternal stress and support physiological birth. https://espace.library.uq.edu.au/view/UQ:339451

[6] NHS England. Health Building Note 09-02: Maternity care facilities. This guidance covers planning and design considerations for maternity care facilities, including birthing rooms, privacy, dignity, daylight, acoustics and the clinical environment. https://www.england.nhs.uk/publication/maternity-care-facilities-planning-and-design-hbn-09-02/

The Benefits of Labouring in Water for Plus-Size Women

Posted on 18 January 202218 June 2026 by K.D.Brainin

Childbirth is a transformative experience, and every expectant mother deserves the opportunity to have a comfortable and empowering birthing experience.

For plus-size women, the challenges of labour and delivery can sometimes be compounded by their body size.

However, one increasingly popular option that offers numerous benefits is labouring in water.

This article explores the advantages of water labour specifically for plus-size women, highlighting how it can enhance their birthing experience and overall well-being.

Buoyancy and Weight Support

One of the primary benefits of labouring in water for plus-size women is the buoyancy and weight support provided by the water.

As water buoys the body, it reduces the gravitational pull on joints and muscles, making it easier for women with larger body sizes to move and change positions during labour.

This buoyancy can alleviate the pressure on the pelvis and lower back, which is especially important for plus-size women who may already experience discomfort in these areas due to their size.

Reference: Geissbuehler V, Stein S, Eberhard J. Waterbirths compared with land births: an observational study of nine years. J Perinat Med. 2004;32(4):308-314.

Pain Relief and Relaxation

Warm water has a natural analgesic effect, helping to ease the pain and discomfort associated with labour contractions.

Plus-size women may have additional challenges due to their size, such as increased strain on the body, making the soothing properties of water particularly beneficial.

Water labour can promote relaxation, reduce stress, and create a calming environment, allowing mothers to focus on their breathing and coping techniques.

Reference: Harper SG, Lynch M, Vernacchio L. “Waterbirth: a retrospective comparative study of waterbirth and land birth outcomes.” Journal of Perinatal Education. 2002;11(2):22-29.

Improved Blood Circulation

For plus-size women, carrying extra weight can sometimes lead to issues with blood circulation and swelling in the extremities.

Immersing in warm water during labour can improve blood circulation by promoting vasodilation, which can help reduce swelling and alleviate discomfort.

Improved circulation can also support the baby’s oxygen supply during contractions.

Reference: Mollamahmutoglu L, Moraloğlu Ö, Ozyer S, et al. Warm showers as an alternative to warm sponges for the management of third stage of labour. European Journal of Obstetrics & Gynaecology and Reproductive Biology. 2002;101(1):19-23.

Enhanced Mobility and Positioning

Water labour allows for greater freedom of movement, which is especially valuable for plus-size women.

The buoyancy of water makes it easier to change positions, squat, or kneel, providing a range of options for comfort and facilitating the progress of labour.

The flexibility to find a comfortable position can be especially important for plus-size women, as it may help prevent complications and reduce the need for interventions.

Reference: Cluett ER, Burns E. Immersion in water in labour and birth. Cochrane Database of Systematic Reviews. 2009(2):CD000111.

Reduced Stress on Joints

The extra weight carried by plus-size women can put strain on their joints and ligaments, potentially leading to discomfort during labour.

Immersion in water can reduce the stress on joints, making movements smoother and less painful.

This can be particularly advantageous during the pushing phase of labour, as it allows for better control and coordination of efforts.

Reference: Zanetti-Daellenbach R, Tschudin S, Zhong X, et al. Influence of immersion in water on uterine contractility and cerebral oxygenation during the first stage of labour. Am J Obstet Gynecol. 2007;196(5):468.e1-8.

Conclusion

Laboring in water offers numerous benefits to plus-size women, enhancing their birthing experience and promoting a sense of empowerment during childbirth.

The buoyancy and weight support of water, coupled with its pain-relieving properties and improved circulation, make it a valuable option for managing the unique challenges associated with labouring while plus-size.

Ultimately, the decision to labour in water should be made in consultation with a healthcare provider, taking into account individual preferences and medical considerations.

Nevertheless, it’s clear that water labour can provide a positive and supportive environment for plus-size women, contributing to a more comfortable and fulfilling childbirth experience.

Active Birth Pools are designed to cater to the specific needs of plus-size women during childbirth

Our pools boast a spacious and ergonomic structure that allows for comfortable movement and positioning during labor.

Their wider dimensions and sturdy construction provide ample room and support for plus-size mothers, ensuring they can find comfortable birthing positions without constraints.

The carefully engineered design also takes into consideration accessibility, making it easier for expectant mothers of all sizes to enter and exit the pool safely.

These pools are equipped with features like grab rails and steps to ensure stability and ease of use.

In essence, the design of active birth pools prioritizes inclusivity and comfort, empowering plus-size women to have a positive and fulfilling birthing experience.

2016 – Launch of the Water Birth Safety Initiative

Posted on 1 January 202211 June 2026 by K.D.Brainin

Hospitals in the United Kingdom began allowing women to use specially designed pools of water for labour and birth during the 1980’s.

The wide-spread popularity and acceptance of water birth pools as a standard part of the maternity care package necessitated the development of guidelines & regulations to define standards and ensure they’re met.

The United Kingdom Department of Health has published a panoply of water safety directives that apply to water birth pools.

Policies and recommendations set forth in the Water Birth Safety Initiative are based upon these publications.

The Water Birth Safety Initiative (WBSI) calls for development of international standards modelled on the UK’s so that women the world over can benefit from the use of water for labour and birth safeguarded from risk.

The WBSI calls for the implementation of stricter protocols and sets forth recommendations for equipment standards.

The guidelines set forth in the WBSI are intended to serve as a framework of standards for birth pool suppliers, hospitals and midwives to work with to establish safe codes of practice.

Guidelines for Water Birth Pools Installed in Hospital

Water is more prone to bacteria growth after it leaves the public water distribution system and enters a building’s plumbing.

There it finds warmer temperatures, stagnation, and smaller pipes, valves and fittings.

Biofilm that forms on valves and fittings and pipe walls not only feeds bacteria but also protects them from the hot water and chlorine that typically would kill free-floating organisms.

Large systems with complex piping networks — like those found in hospitals, hotels and large apartment buildings — are especially prone to bacteria growth.15

Water Birth Pools that are installed in hospitals have the benefit of being maintained by staff to ensure that protocols are established, met and maintained.

Consideration and due diligence with regard to the prospective purchase of water birth pools and the assessment of pools already in use needs to be taken to ensure that the associated plumbing and electrical systems meet relevant safety standards.

The United Kingdom’s Department of Health and National Health Service has an exemplary safety record achieved by establishing rigorous sets of guidelines and regulations for the design, installation, use and maintenance (cleaning/disinfection) of water birth pools.

In the UK water birth pools are classed as a Category Fluid 5 water risk which represents a serious health hazard due to the concentration of pathogenic organisms, radioactive or very toxic substances, e.g. containing faecal material or other human waste; butchery or other animal waste or pathogens.

Water Birth Pools must be installed in compliance with water regulations as set forth in The Water Supply (Water Fittings) Regulations 1999.11

The 7 sins of water safety

To ensure high standards are met it is strongly advised that you do not use a water birth pool that has any of these features:

Overflow drains
Internal water inlets
Hand-held showers
Systems with flexible hoses or extended pipes
Integral or secondary plumbing systems
Any type of recirculating or pumped water systems such as whirlpool, jacuzzi, spa, bubbling, filtering etc
Heating systems

1) Overflow drains

Overflow drains harbour bacteria and can serve as a conduit for cross infection.

Regulations are very clear on this point – overflow drains should not be installed on water birth pools as they constitute a constant infection control risk much more significant than the possible risk of damage due to water overflowing.11,12

Some digital taps on the market can be set for filling time thus obviating the risk of the pool overflowing.

2) Internal water inlets

Internal water inlets act in place of taps to fill the pool.

They are installed on the inside of the pool just above the water line and connected with pipework to a thermostatic valve.

If the water level rises there is a high risk of back flow enabling bacteria to enter the system creating a risk of cross infection.7

3) Handheld showers

Handheld showers present a significant infection control risk due to the fact that they can fall in the pool and be contaminated with bacteria that could breed and be passed on next time the shower is used.

Department of Health regulations clearly stipulate that handheld showers and bath/shower mixers are not installed for use with water birth pools. 13

Handheld showers present a Fluid Category 5 risk to the mains water supply.

It must not be possible to submerge the showerhead in the water due to risk of cross infection.

In order to comply with category 5 water regulations covering back siphonage, a class AUK3 air gap would be required, which generally prevents the use of handsets, unless there is a separate break tank installed in the hospital plumbing system.

4) Systems with flexible hoses or extended pipes

Systems that employ flexible piping, have branch pipes or hold stagnant water present a potential hazard and must not be used with water birth pools.

It is impossible to clean, disinfect or monitor these systems.

They have been proven to be a source of Legionella and Pseudomonas. 14

Weekly flushing recommendations recommended by the department of health cannot be executed with such systems, and the effectiveness of this cannot be monitored due to the inacessibility of the closed system.

5) Integral or secondary plumbing systems

Integral, secondary or proprietary plumbing systems are fitted to some water birth pools.

As these systems can employ flexible and non-flexible piping, overflow drains, handheld showers and are often pumped or recirculating they present a significant infection control risk and should be banned from use.

Regulations stipulate that water birth pools are filled from thermostatically controlled wall mounted mixer taps plumbed directly into the hospitals water supply with the minimum of pipework.

Not only do secondary or integral plumbing systems present unacceptable risks, they are impossible to clean, disinfect or monitor and therefore present an extremely high and unacceptable infection control risk.

They must not be present on pools used for labour and birth. 10

6) Recirculating or pumped water systems

Recirculating or pumped water systems such as whirlpool, jacuzzi, spa, bubbling, filtering etc. have the perfect environmental conditions to be a potential source for the growth of microorganisms, including legionella bacteria and must not be installed on water birth pools.

Water systems that are able produce aerosols represent the highest levels of risk.

Aerosols can be generated very easily when the water surface is broken -for example, by falling water droplets, splashing, or by bubbles breaking at the surface.

Once introduced to artificial water systems, Legionella can thrive in warm water (30 – 35 °C) and has been shown to be present on flexible seals and metal surfaces within plumbing systems used in domestic potable water supplies.

Inadequately maintained spa pools (birth pools with pumped or recirculating systems) provide ideal conditions to support the growth of legionellae and other microorganisms, which may then become aerosolised and subsequently inhaled.15

7) Heating systems

Heating systems for water birth pools are not necessary and present unacceptable infection control risks.7

There are two types of heating systems in use:

1. Recirculating system with a heat exchanger

Water is pumped out of the pool and through a heat exchanger and then flows back into the pool.

These systems present one of the highest infection control risks and should not be installed on a water birth pool under any circumstances. (covered by points 4, 5 and 6 above).

2. Electric heating systems

Similar to under floor heating found in homes do not present an infection control risk.

But, they do present an unacceptable health and safety risk and should therefore not be installed in water birth pools.

These systems consist of a network of cables embedded in the fabric of the birth pool that are attached to the power supply through a thermostat.

The heat is transmitted from the cables through the floor of the pool and then transferred to the water.

The inherent problem with these systems is that the water is relied on to take the heat away from the material.

If a woman remains motionless the heat becomes concentrated and a “hotspot” develops which can result in the woman being burned.

Recommendations

Plumbing for filling and emptying water birth pools should be simple, straight forward and kept to the minimum.

A set of taps (see below) mounted on the wall 15cm above the rim and a drainage system similar to that of a normal bath is all that is required.

Rim mounted taps present two areas of risk:

1. Women may hit their head on taps that are mounted on the rim of the pool causing injury.

In the throes of labour a woman is not as cognisant of her surroundings as she normally is.

She needs to be protected from the potential harm that could result from hitting her head or other part of her body on the spout.

2. Risk to the taps and pool caused by the labouring woman grabbing onto the spout for support could easily cause damage to the fitting or fabric of the pool.

Filling the birth pool

Water Birth Pools should be filled directly from the hospitals main water supply through a ¾ Thermostatic Mixing Valve (TMV).

To comply with UK National Health Service regulations the valve must have TMV3 approval for use in Healthcare and Commercial situations and certify that it conforms to the performance requirements of the Department of Health.16

To kill legionella and other bacteria, water in hospitals systems is heated to 60 – 80 °C.

Water temperature entering the birth pool should be limited by the TMV to 44 °C to prevent scalding.

The added benefit of using a TMV connected directly to the hospitals main water supply is that it can be set to automatically flush itself of stagnant water twice a day and be thermally disinfected periodically.

The use of a TMV ensures a safe water supply.

Digital thermostatic mixing valves with enhanced thermal performance that incorporate these features are ideal:

1) Programmable control to accurately mix and maintain the temperature of the water flowing into the birth pool and limit the temperature of the water to 44 °C to prevent scalding.17

2) Programmable fill duration to fill the pool to the desired depth and then turn off.

This is important as water birth pools are not allowed to have overflow drains installed and this feature will prevent the pool from overflowing when unattended.

3) Programmable duty flushing to ensure that water does not stagnate within the tap and associated pipe work, effectively controlling the multiplication of legionella & other bacteria in infrequently used outlets.

Flushing duration is in line with HSE L8 recommendations.18

4) Programmable high-temperature thermal disinfection to destroy the proteins in viruses and bacteria and render them as dead or inert.

Thermal disinfection works by achieving a moist heat which is set at a specific temperature for a set amount of time.

Viruses and bacteria are very sensitive to heat and they will die if exposed to higher temperatures. 19

Emptying the Pool

Water from a birth pool needs to be treated as Fluid category 5 waste representing a serious health hazard due to the concentration of pathogenic organisms derived from fecal material or other human waste and emptied directly into the hospital’s waste water system.20

The pipework needs to have a trap or U bend fit as close to the waste/drain as possible.

The drainage fitting or waste should seal neatly into the drain.

The drainage fitting should be cleaned and flushed through with disinfectant and then dried as part of the cleaning protocol.

The waste should be kept closed when the pool is not in use.

There should be NO flexible pipe used in the drainage pipework.21

The waste should be remotely operated (i.e. pop up waste with rim mounted control) and of the best quality, preferably high-grade brass, to resist the corrosive action of chlorides and other disinfectants.

End notes

The Water Birth Safety Initiative was conceived by Keith Brainin to motivate and enable birth pool suppliers and health care professionals to raise standards and implement protocols to make water birth safe.

References

[1] Healio – Infectious Disease News. (2014, December 26). Legionellosis death after water birth sparks call for stricter infection control protocols. http://www.healio.com/infectious-disease/practice management/news/online/%7Bfe352169-755d-4d21-9bb2-abb8ae209f89%7D/legionellosis-death-after-water-birth-sparks-call-for-stricter-infection-control-protocols

[2] Inquisitr. (2015, January 16). Oregon Water Birth Leaves Baby Disabled, Lawsuit Wants Labor Options Banned. http://www.inquisitr.com/1761136/oregon-water-birth-leaves-baby-disabled-lawsuits-wants-labor-options-banned/

[3] GOV.UK. Alert after Legionnaires’ disease case in baby, 2014. https://www.gov.uk/government/news/alert-after-legionnaires-disease-case-in-baby

[4] The Guardian. Legionnaires’ disease in baby is linked to heated birthing pool, June 17, 2014.http://www.theguardian.com/society/2014/jun/17/legionnaires-disease-heated-birthing-pool-baby-public-health

[5] Guidance from the Water Regulations Advisory Scheme (WRAS) https://www.wras.co.uk/consumers/advice_for_consumers/what_are_the_water_regulations_/

[6] M.W. LeChevallier, 2003 World Health Organization (WHO). Conditions favouring coliform and HPC bacterial growth in drinking- water and on water contact surfaces. Heterotrophic Plate Counts and Drinking-water Safety. Edited by J. Bartram, J. Cotruvo, M. Exner, C. Fricker, A. Glasmacher. Published by IWA Publishing, London, UK. ISBN: 1 84339 025 6.

[7] www.gov.uk. Public Health England advice on home birthing pools, 2014. https://www.gov.uk/government/news/public-health-england-advice-on-home-birthing-pools

[8] Health and Safety Executive. (2013). Legionnaires’ disease: Technical guidance [3.4], 2013. http://www.hse.gov.uk/pubns/priced/hsg274part3.pdf

[9] United Lincolnshire Hospitals NHS Trust UK. Cleaning, Disinfection and Sterilization Guidelines for Re-Usable Medical Devices 2010.
http://www.activebirthpools.com/wp-content/uploads/2014/05/Lincolnshire-CLEANING-DISINFECTION-AND-STERILIZATION-GUIDELINES-FOR-RE-USABLE-MEDICAL-DEVICES.pdf

[10] http://www.eurosurveillance.org. Case of legionnaires’ disease in a neonate following an home birth in a heated birthing pool. England, June 2014 http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=20857

[11] Water Regulations Advisory Scheme (WRAS). Fluid Categories. https://www.wras.co.uk/consumers/resources/glossary/fluid_categories/

[12] WHBN 00-10 Welsh Health Building Note. Part C: Sanitary assemblies2014, http://www.wales.nhs.uk/sites3/documents/254/WHBN%2000-10%20Part%20C.pdf

[13] Department of Health, Children, young people and maternity services. Health Building Note 09-02: Maternity care facilities, 2009.
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/147876/HBN_09-02_Final.pdf

[14] Freije, Matthew R. Some waterborne bacteria are tough, 2010. http://www.watertechonline.com/articles/some-waterborne-bacteria-are-tough

[15] Woolnough, Kevin. Legionella Expert Calls for Greater Vigilance, 2014. http://www.eurofins.co.uk/news-archive/legionella-expert-calls-for-greater-vigilance.aspx

[16] BEAMA. TMV Standards and regulations, 2013. http://www.beama.org.uk/en/product-areas/heating-hot-water–air-movement/thermostatic-mixing-valves/tmva-faqs-on-thermostatic-mixing-valves/tmv-standards-and-regulations.cfm

[17] Health and Safety Executive. Managing the risks from hot water and surfaces in health and social care, 2012. http://www.hse.gov.uk/pubns/hsis6.pdf

[18] Health and Safety Executive. Legionnaires’ disease The control of legionella bacteria in water systems, 2013. http://www.hse.gov.uk/pubns/priced/l8.pdf

[19] Health and Safety Executive. Managing legionella in hot and cold water systems. http://www.hse.gov.uk/healthservices/legionella.htm

[20] SMS Environmental – the water experts. Fluid Categories. http://www.sms-environmental.co.uk/fluid_categories.html.

[21] Nottingham University Hospitals NHS Trust. Legionella Management and Control Procedures, 2014.

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Dekker, Rebecca. “Evidence on the Safety of Water Birth.” http://evidencebasedbirth.com/. 2014. http://evidencebasedbirth.com/waterbirth/ (accessed 2014 10-09).

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Healio – Infectious Disease News. Legionellosis death after water birth sparks call for stricter infection control protocols. 2014. http://www.healio.com/infectious-disease/practice-management/news/online/%7Bfe352169-755d-4d21-9bb2-abb8ae209f89%7D/legionellosis-death-after-water-birth-sparks-call-for-stricter-infection-control-protocols (accessed 2015 07-01).

Health and Safety Executive. Legionnaires’ disease The control of legionella bacteria in water systems. 2013. (accessed 2014 07-07).

—. “Legionnaires’ disease: Technical guidance.” 2013. http://www.hse.gov.uk/pubns/priced/hsg274part3.pdf (accessed 2014 20-10).

—. Managing legionella in hot and cold water systems. http://www.hse.gov.uk/healthservices/legionella.htm (accessed 2015 07-01).

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Health Facilities Scotland. Consultation draft of SHTM 04-01 Water Safety for Healthcare Premises Part G: Operational Procedures and exemplar Written Scheme 2013. Health Facilities Scotland.

Inquisitr. Oregon Water Birth Leaves Baby Disabled, Lawsuit Wants Labor Options Banned. 2015.http://www.inquisitr.com/1761136/oregon-water-birth-leaves-baby-disabled-lawsuits-wants-labor-options-banned/ (accessed 2015 16-01).

Laura Franzin, Carlo Scolfaro, Daniela Cabodi, Mariangela Valera, and Pier Angelo Tovo. Legionella pneumophila Pneumonia in a Newborn after Water Birth: A New Mode of Transmission. Oxford Journals, November 2001: 104.

Legionella Control. Birthing Pool Death Linked To Legionnaires disease. https://legionellacontrol.com/blog/166-birthing-pool-death-linked-to-legionnaires-disease (accessed 2014 27-11).

Legislation.gov.uk. The Water Supply (Water Fittings) Regulations 1999.The National Archives. 1999. http://www.legislation.gov.uk/uksi/1999/1148/contents/made (accessed 2015 05-01).

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N Phin, T Cresswell, F Parry-Ford on behalf of the Incident Control Team. CASE OF LEGIONNAIRES’ DISEASE IN A NEONATE FOLLOWING A HOME BIRTH IN A HEATED BIRTHING POOL, ENGLAND, JUNE 2014.http://www.eurosurveillance.org. 2014. http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=20857 (accessed 2015 10-01).

Nottingham University Hospitals. LEGIONELLA MANAGEMENT AND CONTROL PROCEDURES. May 8, 2014.

Rosanna A. Zanetti-Daellenbach, Sibil Tschudin, Xiao Yan Zhong, Wolfgang Holzgreve, Olav Lapaire, Irene Ho ̈sli. Maternal and neonatal infections and obstetrical outcome in water birth . Prod. Women’s University Hospital Basel. Spitalstrasse, Basel: European Journal of Obstetrics & Gynecology and Reproductive Biology , 2006 28-August.

SMS Environmental – the water experts. Fluid Categories. http://www.sms-environmental.co.uk/fluid_categories.html.

Takuhito Nagai, Hisanori Sobajima, and Mitsuji Iwasa. A fatal newborn case of Legionella pneumophila pneumonia occurring after water birth in a bathtub with an all day circulating system, June 1999 – Nagoya City.http://idsc.nih.go.jp/. 2000. http://idsc.nih.go.jp/iasr/21/247/de2474.html (accessed 2014 17-06).

Takuhito Nagai, Hisanori Sobajima, Mitsuji Iwasa, Toyonori Tsuzuki, Fumiaki Kura, Junko Amemura-Maekawa, and Haruo Watanabe. Neonatal Sudden Death Due to Legionella Pneumonia Associated with Water Birth in a Domestic Spa Bath. 2002.http://www.ncbi.nlm.nih.gov/pmc/articles/PMC154682/ (accessed 2014 3-12).

The Guardian. Legionnaires’ disease in baby is linked to heated birthing pool . 2014. http://www.theguardian.com/society/2014/jun/17/legionnaires-disease-heated-birthing-pool-baby-public-health (accessed 2014 18-June).

U.S. Department of Health and Human Services Centers for Disease Control and Prevention (CDC) Atlanta, GA 30333. Guidelines for Environmental Infection Control in Health-Care Facilities . 2003.

UNITED LINCOLNSHIRE HOSPITALS NHS TRUST. CLEANING, DISINFECTION AND STERILIZATION GUIDELINES FOR RE-USABLE MEDICAL DEVICES. Lincolnshire, 2010 January.

Water Regulations Advisory Scheme. Fluid Categories . https://www.wras.co.uk/consumers/resources/glossary/fluid_categories/ (accessed 2014 3-12).

which.co.uk. Having a water birth and using birth pools. http://www.which.co.uk/birth-choice/articles/using-water-in-labour.

Woolnough, Kevin. Legionella Expert Calls for Greater Vigilance. http://www.eurofins.co.uk/news-archive/legionella-expert-calls-for-greater-vigilance.aspx (accessed 2015 17-01).

Please feel free to distribute and share this document crediting © K. D. Brainin (Active Birth Pools) 2015

The Warm Embrace: How Warm Water in Water Birth Pools Facilitates the Release of Oxytocin

Posted on 3 January 202130 January 2024 by K.D.Brainin

The use of water birth pools has gained popularity in recent years as expectant mothers seek alternatives that enhance the natural birthing experience.

One of the key factors contributing to the success of water births is the warm water in the birthing pool, creating an environment that encourages the release of oxytocin.

Often referred to as the “love hormone” or “bonding hormone,” oxytocin plays a crucial role in the progression of labour and the overall well-being of both mother and baby.

Understanding Oxytocin:

Oxytocin, produced by the hypothalamus and released by the pituitary gland, is a hormone known for its role in promoting social bonding, emotional connection, and uterine contractions during childbirth.

It is often associated with feelings of love, trust, and intimacy, and its presence is pivotal in the birthing process.

The Warm Water Effect:

Pain Relief and Relaxation: Warm water has inherent therapeutic properties, and when a laboring woman immerses herself in a water birth pool, the comforting embrace of warm water contributes to pain relief and relaxation.

The buoyancy of water alleviates the pressure on the body, reducing muscle tension and creating an environment conducive to calmness.

As the mother relaxes, the body is more apt to release oxytocin, facilitating the progression of labor.

Enhancing Blood Circulation:

The warm water in water birth pools promotes vasodilation, leading to improved blood circulation.

This enhanced blood flow is particularly beneficial during childbirth, as it ensures that the uterus receives an adequate supply of oxygen and nutrients.

The improved circulation helps in optimizing uterine contractions and, subsequently, the release of oxytocin.

Reducing Stress Hormones:

Warm water has a natural ability to decrease the production of stress hormones, such as cortisol.

By creating a serene and comfortable environment, the water birth pool minimizes the stress response, allowing the body to focus on the release of oxytocin.

This reduction in stress hormones supports a positive birthing experience and contributes to the mother’s overall well-being.

Facilitating the Bonding Process:

Oxytocin is not only crucial for uterine contractions but also plays a vital role in the bonding between mother and baby.

The warm water in the birthing pool promotes the release of oxytocin, fostering a sense of intimacy and connection between the mother and her newborn.

This early bonding experience can have lasting positive effects on the emotional well-being of both mother and child.

Promoting a Positive Birth Environment:

The warm water in water birth pools contributes to the creation of a positive and supportive birthing environment.

This positive ambiance, coupled with the physiological effects of warm water, enhances the mother’s overall experience, making her more receptive to the natural release of oxytocin.

Conclusion:

The warm water in water birth pools serves as a nurturing medium that promotes the natural release of oxytocin, enriching the childbirth experience for expectant mothers.

As healthcare providers and birthing centers continue to recognize the benefits of water immersion during labor, understanding the interplay between warm water and oxytocin release becomes essential.

By harnessing the therapeutic properties of warm water, the journey through childbirth becomes not only more comfortable but also profoundly connected, nurturing the beautiful bond between mother and baby.

A way to make labour shorter, easier and more comfortable

Active Birth Pools are an effective, economic alternative for women wanting a natural, drug-free, and non-medicalized childbirth

Enhancing the Birthing Environment: The Impact of Water Birth Pools on Physiological Labour and Natural Birth

Sheila Kitzinger – Birth in Water: Just a Fad?

Posted on 17 August 202023 August 2024 by K.D.Brainin

Originally published December 11, 2014

World-renowned social anthropologist and birth activist Sheila Kitzinger (1929-2015) was a strong advocate for birth in water, known as waterbirth.

A voice for the ability for every woman to choose, Sheila believed that waterbirth should be an option in mainstream maternity care.

In this piece for Birth Institute, Sheila outlined some of the myths surrounding the birth method, and provides evidence that, in fact, waterbirth is a safe, effective and empowering birthing option.

Learn how to support women through labor and delivery in water. Become a midwife!

Waterbirth is often discussed as if it were a novelty – and a dangerous one at that. It has been assumed to be something that “dropouts” and “weirdoes” choose, or that it is just a recent, passing phenomenon.

In truth, birthing in water is a safe and widespread practice among hospitals in the UK and Western Europe – including Switzerland, Italy, Spain, Portugal, Malta, Denmark, Norway and Finland.

Furthermore, most practices aren’t as new as we think (the Ostend Aquanatal Centre in Belgium has been going strong since the late 80s), and waterbirth practices are here to stay.

Birth in water is safe and effective

Swiss study reveals that when using a pool women require less analgesia, have a lower incidence of perineal trauma, and reduced blood loss at delivery.

NICE (National Institute for Health and Care Excellence) concludes that waterbirth ‘provides the safest form of pain relief’.

There is evidence that being in water improves uterine contractility and speeds dilatation. So, awoman giving birth in water is less exposed to interventions, including artificial augmentation of uterine activity, and is more likely to feel happy about her birth experience afterwards.

Yet that may not only be due to the water. Labouring women who give birth in water have more one-to-one care from a midwife they have come to know.

This, combined with a relaxed environment in which the pool is used, contributes to the positive results. More first time mothers have spontaneous births in a freestanding midwifery center or at home than those in hospital.

In the UK, the NHS (National Health Service) states that women should be able to use a pool if they wish, and recommends one be available for every thousand women.

This option has become part of mainstream maternity care, and approximately 75% of all hospitals in the UK have installed birthing tubs.

Many community midwives are eager to raise the homebirth rate, and portable pools, designed to be used by just one woman (to avoid cross-infection), are selling well.

Complicated waterbirthing pools are not necessary.

Chairs, stools and other contraptions restrict movement, and when a woman is immobilized she is more likely to need obstetric intervention.

Francoise Freedman of Birthlight in Cambridge suggests using a pool at home to explore yoga movements during pregnancy.

These include hip-openers, kneeling stretches, and those to prevent and ease back pain, and others for ribcage expansion and pelvic floor toning.

The warm water acting as a cushion also makes a comfortable space to practice perineal massage.

Waterbirth is here to stay

Midwives keen on home birth and waterbirth were once seen as dissidents and mavericks.

This has changed now – so much that in the UK, it is common to encourage women to choose to labour, and perhaps give birth, in water and in their own home. Pregnant women and midwives are being empowered now.

Every midwife-run and staffed birth center for low risk women offers pools, and midwives are beginning to develop the skills to use them. There is a feast of research from which midwives can learn more.

Ethel Burns, Waterbirth Practitioner, Research Midwife and Midwifery Teacher, and I have drawn up recommendations for practice in a paper available from Oxford Brookes University (read it here).

Sheila Kitzinger (1929-2015) was a social anthropologist of birth and an advocate of home births. She believed that women have the right to decide the place of birth and kind of care they prefer, and to make an informed choice, based on research and their own values.

Women suffering post-traumatic stress after birth would ring her for help, seeking the confidence to deal with it. For years she worked with mothers and babies in prison and asylum centers. She lectured all over the world and her books are published in 23 languages.

Exploring movements in Water

Sheila was a keen proponent of water birth.

Her wonderful article gives us examples of the type and range of movements natural to labour and birth that mothers explore in water.

The pool in the photos is an original Oval Portable Water Birth Pool circa 1987 – to my knowledge the first specially designed portable water birth pool ever produced.

Please click here for a copy of Exploring movements in water:

Why Water Birth Pools are Sanitary Equipment, Not Medical Devices

Posted on 12 February 202012 June 2026 by K.D.Brainin

Position statement: A professional water birth pool is a hospital-grade sanitary product: a specialised bath used to contain clean water for immersion during labour and birth. Its core function is hygienic water containment, not diagnosis, monitoring, treatment, therapy, drug delivery or physiological intervention.

Water birth pools are used in maternity care, but their healthcare setting does not automatically make them medical devices. A product should be classified according to its design, function, materials, intended purpose and applicable regulatory category – not merely by the fact that it is installed in a hospital or birth centre.¹

On that basis, a professional water birth pool is best understood as sanitary equipment: a specialised bath used to contain clean water for immersion during labour and birth. It is not a diagnostic device, not a therapeutic apparatus, not a life-support system and not an instrument that acts on the body by medical, pharmacological, immunological or metabolic means.²

The intended purpose is immersion in water

The core purpose of a water birth pool is straightforward: to provide a safe, hygienic, ergonomically designed vessel for water immersion during labour and birth. Active Birth Pools describes its products as professional water birth pools for hospitals, birth centres and maternity units, and describes the Venus model as a hospital-grade water birth pool whose dimensions and depth are designed to facilitate free movement and maximise the benefits of water immersion during labour.³

Water immersion may help women feel more comfortable, mobile, relaxed and supported during labour, but the pool itself does not diagnose, monitor, prevent or treat a disease or injury. It does not administer medication. It does not modify anatomy or physiology through a medical action. It is a passive item of sanitary equipment that holds water.⁴

This distinction is important. Many items are used in healthcare environments without being medical devices. Hospital baths, sinks, taps, toilets, showers, basins, sanitary fittings and clinical furniture may all contribute to patient care, but they are not automatically medical devices. They are specified, installed, cleaned and maintained as part of the built environment and hygiene infrastructure of a healthcare facility. A water birth pool belongs in this same category.

Customs classification supports sanitary-ware status

The Harmonised System classification for plastic baths and similar sanitary ware supports this interpretation. HS heading 3922 covers baths, shower-baths, sinks, washbasins, bidets, lavatory pans, seats and covers, flushing cisterns and similar sanitary ware of plastics. Subheading 3922100000 covers baths, shower-baths, sinks and washbasins of plastics.⁵

This is significant because customs classification reflects the essential character of the goods. A water birth pool made from specialist composite or plastic materials has the essential form and function of a bath: it is filled with water, used for immersion, drained, cleaned and disinfected between uses. The fact that the bath is designed for maternity environments does not change its essential nature as sanitary equipment. It is a professional, hospital-grade bath, but it remains sanitary ware.

The NMPA decision confirms the principle

The classification decision issued by China’s National Medical Products Administration (NMPA) for the Venus Water Birth Pool is particularly important. The decision letter identifies the product as “Active Birth Pool” / “Venus Water Birth Pool” and states: “NMPA decided that your device is not a medical device.”⁶

That decision is consistent with the product’s intended purpose and mode of action. A water birth pool does not perform a medical function in the way that a monitor, infusion pump, surgical instrument or diagnostic apparatus does. It is used to support the environment in which care is provided, rather than to provide medical treatment itself. A product can be important to safe maternity care without being a medical device.

The SABER certificate treats the product as sanitaryware

The Saudi SABER certificate also supports classification as sanitary equipment. It describes the model and product name as “Plastic bathtub”, with the trade mark “active birthpools”, country of origin “United Kingdom”, and manufacturer “Design & Form Limited”. It records a conformity assessment decision of “Product Approved”.⁷

Most importantly, the certificate places the product under the “Technical Regulation for Building Materials – Part 4: Bricks, Tiles, Ceramics, Sanitaryware and Related Products”. That is a building-materials and sanitaryware route, not a medical-device route.⁸

This aligns with how water birth pools are procured and installed in hospitals. They are part of the maternity room’s sanitary infrastructure, requiring appropriate materials, plumbing, drainage, cleaning access, infection-control features and durability. These are sanitary and building-performance considerations, rather than medical-device performance claims.

Infection control is a sanitary-design requirement

Infection control is one of the main reasons hospital water birth pools must be designed as professional sanitary equipment. A birth pool must be easy to clean, resistant to disinfectants, free from unnecessary joints and fittings, and designed to avoid areas where microorganisms can accumulate. Materials, surface finish, drainage design and the avoidance of recirculating pipework are critical.⁹

Active Birth Pools’ published cleaning information states that Ficore is resistant to disinfection with 10,000 ppm hypochlorite and that seamless one-piece construction, together with the absence of surface-mounted metalwork, denies microorganisms the environment they need to propagate.¹⁰

These features do not make the pool a medical device. They make it better sanitary equipment. The same principle applies to hospital sinks, clinical baths and other sanitary installations: infection control is essential, but that does not convert sanitaryware into a medical device. It means the sanitaryware must be properly designed for a healthcare environment.

Hospital-grade does not mean medical device

The phrase “hospital-grade” should refer to strength, durability, hygiene, cleanability, safe access, ergonomic design, resistance to disinfectants and suitability for repeated use in a clinical setting. It should not be taken to mean that the product has a medical mode of action or requires medical-device classification.

A hospital-grade birth pool is a specialised sanitary product for maternity settings. Its performance should be judged by sanitary-ware standards, infection-control requirements, building and plumbing regulations, material safety, durability and user safety.

Why correct classification matters

Correct classification protects hospitals, distributors, regulators and manufacturers. If a water birth pool is incorrectly treated as a medical device, purchasers may be led into the wrong regulatory pathway. That can create unnecessary cost, confusion and delay without improving safety. It may also distract attention from the standards that matter most: sanitary design, cleanability, water safety, plumbing safety, manual handling, durability and infection prevention.

Conversely, classifying a water birth pool as sanitary equipment ensures that it is assessed according to its true risks and real-world use. The key questions are:

Does the pool diagnose, monitor or treat a medical condition? No.
Does it administer medication or act on the body by medical means? No.
Does it provide a hygienic vessel for water immersion? Yes.
Is its essential character that of a specialist bath or sanitary fixture? Yes.

That is why the correct classification is sanitary equipment.

Conclusion

Water birth pools are used in maternity care, but they are not medical devices. They are specialised sanitary equipment designed for hospitals, birth centres and maternity units.

Their purpose is to provide a safe, durable, hygienic and comfortable vessel for water immersion during labour and birth. Their critical performance requirements relate to sanitary design, cleanability, infection control, plumbing safety, durability and ergonomics.

The HS sanitary-ware classification, the NMPA decision that the Venus Water Birth Pool is not a medical device, and the SABER certificate identifying the product as a plastic bathtub under sanitaryware-related building materials regulation all support the same conclusion. A professional water birth pool should therefore be specified, procured and regulated as hospital-grade sanitary equipment – not as a medical device.

Notes

Classification should be based on intended purpose, design and mode of action. The healthcare setting is relevant context, but it is not determinative by itself.
The MHRA describes medical-device purposes as including diagnosis, prevention, monitoring, treatment or alleviation of disease; diagnosis, monitoring, treatment, alleviation of or compensation for injury or handicap; investigation, replacement or modification of anatomy or a physiological process; or control of conception. A passive water-containment bath does not naturally fall within those medical purposes.
Active Birth Pools’ website says the company has focused since 1987 on designing professional water birth pools for hospitals, birth centres and maternity units. The Venus product page describes the model as hospital-grade and designed for free movement and water immersion during labour.
This article distinguishes between clinical benefits associated with water immersion and the regulatory character of the pool itself. The product provides the vessel/environment; it does not itself perform a medical act.
HS 3922 is the international customs heading for plastic sanitary ware; 3922100000 is for baths, shower-baths, sinks and washbasins of plastics. This supports sanitary-equipment classification. Note: the uploaded SABER certificate records HS Code 392290000001, which is also within heading 3922 for plastic sanitary ware, rather than a medical-device heading.
NMPA Decision Letter of Medical Device Official Classification, Acceptance No. W20200222, Decision Letter No. 20200331003. The product is identified as Active Birth Pool / Venus Water Birth Pool and the decision states that it is not a medical device.
SABER Certificate of Conformity for Regulated Products, Certificate No. 69797-109-24-1490492, issue date 30 July 2024, expiry date 30 July 2025. Page 1 describes the product as Plastic bathtub, trade mark active birthpools, country of origin United Kingdom.
SABER certificate, page 2: Technical Regulation for Building Materials – Part 4: Bricks, Tiles, Ceramics, Sanitaryware and Related Products; Manufacturer name Design & Form Limited; conformity assessment decision Product Approved.
Infection prevention is a central requirement for sanitary equipment used in clinical environments. It is not, on its own, evidence of a medical-device function.
Active Birth Pools’ cleaning guidance states that Ficore is immune to the effects of disinfection with 10,000 ppm hypochlorite and that seamless one-piece construction and the absence of surface-mounted metalwork deny microorganisms the environment they need to propagate.

References

Active Birth Pools, homepage. https://activebirthpools.com/
Active Birth Pools, Venus II / 360 Birth Pools product page. https://activebirthpools.com/products/venus-birth-pools/
Active Birth Pools, Cleaning and Care. https://activebirthpools.com/cleaning-care/
Active Birth Pools, Delivery and Installation / Cleaning and Disinfection Guidelines. https://activebirthpools.com/installation-manual/
UK Medicines and Healthcare products Regulatory Agency, Medical devices: how to comply with the legal requirements. https://www.gov.uk/guidance/medical-devices-how-to-comply-with-the-legal-requirements
Tariff Number, HS Code 39221000 – Baths, shower-baths, sinks and washbasins, of plastics. https://www.tariffnumber.com/2026/39221000
TARIC Support, Heading 3922 – Baths, shower-baths, sinks, washbasins and similar sanitary ware of plastics. https://www.taricsupport.com/nomenclature/en/3922000000.html
UK Government tariff notice 19, Shower-baths: classification under CN code 3922 10 00. https://www.gov.uk/guidance/shower-baths-tariff-notice-19
Saudi Standards, Metrology and Quality Organization, Technical Regulation for Building Materials – Part 4: Bricks, Tiles, Ceramics, Sanitary Ware and Related Products. https://saso.gov.sa/en/Laws-And-Regulations/Technical_regulations/Documents/TR%20-%20Building%20Materials%20-%20Part%204%20Bricks%20Tiles%20Ceramics%20Sanitary%20Ware%20and%20Related%20Products.pdf
NMPA Decision Letter of Medical Device Official Classification, Active Birth Pool / Venus Water Birth Pool, Acceptance No. W20200222, Decision Letter No. 20200331003. Uploaded file: Decision Letter of Medical Device Official Classification-EN.pdf
SABER Certificate of Conformity for Regulated Products, Certificate No. 69797-109-24-1490492. Uploaded file: Saber Certificate.pdf

Regulatory caveat

This article is a classification and positioning brief based on the sources listed above. It is not legal advice. Local regulatory classifications can depend on precise intended-use claims, labelling, market, product configuration and the view of the competent authority.

Enhancing Midwifery Care: The Benefits of Water Birth Pools

Posted on 3 January 202014 March 2024 by K.D.Brainin

Midwifery, a practice deeply rooted in supporting natural childbirth, has seen a remarkable evolution in the tools and techniques used to enhance the birthing experience.

Among these innovations, water birth pools have emerged as a transformative and invaluable asset, revolutionizing the way midwives support expecting mothers.

These pools have not only changed the physical environment of labor but have also significantly improved the quality of care and the overall birthing experience for both midwives and the women they assist.

Creating an Ideal Birthing Environment

Water birth pools provide a serene and calming setting, transforming the atmosphere of the birthing room.

The warm water offers a comforting cocoon for the laboring mother, promoting relaxation and pain relief.

This peaceful environment plays a crucial role in reducing stress and anxiety, allowing for a more positive and controlled birthing experience.

Benefits for Midwives

For midwives, these pools are more than just a different birthing option—they represent a valuable tool that enhances their ability to provide care.

Here’s how water birth pools make a difference for midwives:

Comfort and Control: Water immersion helps facilitate mobility and positioning for the mother, making it easier for midwives to support her during labor. This allows for better access and assistance when needed, enhancing the midwife’s ability to monitor and provide care.
Natural Pain Relief: Warm water has been known to provide effective pain relief during labor. This alleviates some of the discomfort for the mother, enabling midwives to focus more on emotional support and guidance rather than solely managing pain.
Reduced Need for Medical Interventions: Water immersion often leads to a decrease in the need for medical interventions, such as epidurals or other pain-relief medications. Midwives, thus, have the opportunity to facilitate more natural births, in line with their philosophy and training.
Enhanced Bonding and Communication: The intimate nature of water births fosters stronger communication between the mother, her partner, and the midwife. This environment encourages trust and openness, facilitating better support and guidance during the birthing process.

Challenges and Considerations

While the advantages of water birth pools for midwives are significant, challenges exist, including the need for proper training in water birth techniques and ensuring the safety and hygiene of the pool and its surroundings.

Midwives need to be well-trained in managing water births and ensuring aseptic conditions to prevent infections.

The Future of Midwifery with Water Birth Pools

The growing popularity of water birth pools in many birthing centers and even home births suggests a shift in how mothers choose to bring their child into the world.

This, in turn, influences the practice of midwifery.

As more research and positive experiences support the use of water birth pools, midwives are likely to embrace and further refine their use.

Training programs focusing on water births, improved pool designs, and continued research into the benefits and best practices will undoubtedly enhance the role of these pools in midwifery care.

Conclusion

Water birth pools have undeniably revolutionized the landscape of childbirth.

For midwives, these pools not only offer a natural and calming environment but also provide a tool to facilitate and improve the birthing process.

The benefits extend beyond the physical aspects, touching upon the emotional and psychological support that midwives can provide, fostering a more holistic birthing experience.

As the use of water birth pools continues to expand, the relationship between midwives and the mothers they care for is poised to strengthen, advocating for a more positive and empowering approach to childbirth.

Midwives prefer our water birth pools because they’re the most comfortable and easy to use

Active Birth Pools: Manual Handling

Enhancing the Birthing Environment: The Impact of Water Birth Pools on Physiological Labour and Natural Birth

The benefits of using water for labour and birth are well known, here are the facts…

Posted on 16 May 201927 February 2023 by K.D.Brainin

The benefits of using water for labour and birth are well known…

Here are the facts…

Relaxing in a deep pool of warm water can be a wonderful aid in labour. It’s worth having a pool mainly for this reason.
Using a birth pool helps mothers to manage pain in labour and considerably reduces the need for medical pain relief.
The buoyancy of the water supports the mothers body weight allowing her to relax more easily and deeply. They can cope better with contractions and also rest more comfortably in between them.
It’s easier to use upright or squatting positions and move freely from one position to another, than it is on land.
Being in a birth pool gives mothers an increased feeling of privacy and security. This enhances the secretion of hormones which stimulate uterine contractions and act as natural pain killers and relaxants.
Studies show that labours tend to be shorter overall when a woman enters the pool at around 5cms. dilation.
Fewer women need the help of obstetric interventions.

Women who receive less medical intervention generally stay in hospital for a shorter period of time.

The combination of an intervention free birth – with a short hospital stay result in a better experience for mother and baby.

Hospital staff and resources can be employed more efficiently.

Importantly – this results in significant financial savings!

A birth pool is a simple, inexpensive piece of equipment that has a major impact on the the quality of care and cost of having a baby.

Click here to learn more about our water birth pools and find out how they will deliver for you.

Some water borne bacteria are tough

Posted on 27 March 201915 September 2024 by K.D.Brainin

Originally published by Matthew R. Freije in 2013

Water is more prone to bacteria growth after it leaves the public water distribution system and enters a building’s plumbing. There it finds warmer temperatures, stagnation, and smaller pipes, valves and fittings.

Biofilm that forms on valves and fittings and pipe walls not only feeds bacteria but also protects them from the hot water and chlorine that typically would kill free-floating organisms.

Large systems with complex piping networks — like those found in hospitals, hotels and large apartment buildings — are especially prone to bacteria growth, but home plumbing systems are not exempt.

In fact, Legionella bacteria have been found in many home plumbing systems, some of which have been implicated in cases of Legionnaires’ disease.

Closer look at waterborne bacteria

Not all types of bacteria are unhealthy; some actually protect humans from illness. Only the disease-causing (pathogenic) bacteria are a concern, and these include Pseudomonas aeruginosa, Helicobacter pylori, Legionella, E. coli and Mycobacteria avium.

Many pathogens that can be transmitted from water also can be transmitted from food or surfaces or passed from person to person. For Legionella, however, water is nearly always the source.

Transplant patients, smokers, the elderly, persons with underlying disease such as cancer or diabetes, or patients undergoing chemotherapy treatment are many times more likely than a young nonsmoker in generally good health to become infected by waterborne bacteria and to die from that infection.

Modes of transmission

Drinking water is only one of the ways in which harmful bacteria can enter a person’s body.

Some bacteria can be inhaled in small droplets while showering, brushing teeth or washing the face.

Even while washing hands, a person could unknowingly inhale small water droplets that become airborne directly from the faucet or after water splashes against the sink.

Water droplets can enter the lungs and cause infection also by aspiration: contaminated water in the mouth, perhaps while swallowing, gets past the choking reflexes and enters the lungs instead of the esophagus and stomach.

Aspiration is more likely to occur in smokers, because their damaged respiratory tracts fail to keep substances out of the lungs.

Water-related illness associated with skin contact is less common in generally healthy people.

However, Pseudomonas aeruginosa has caused skin rashes in people using swimming pools or whirlpool spas that have not been properly treated to kill bacteria.

All four modes of transmission — ingestion, inhalation, aspiration and skin contact — have one crucial fact in common: The source of the problem is in the water.

If the water is not contaminated, illness will not occur.

Reducing risk

Bear in mind that the following comments pertain only to home plumbing systems. Some methods that are effective in home plumbing systems will not work well in hospitals, hotels or other large buildings.

Chemical disinfection

The disinfectant in a public water supply cannot be relied upon to control pathogens in a home plumbing system.

The free chlorine concentration varies significantly from city to city and even within a given distribution system, depending in part on the distance from the treatment plant to a home.

The water entering some homes may have 1.0 part per million (ppm) free chlorine while others will have 0.2 ppm or less.

Moreover, hot water at faucets and showers is unlikely to have any disinfectant, as chlorine concentrations are likely to dissipate in the water heater.

Although two studies conducted by the Centers for Control of Disease and Prevention (CDC) indicated that city water systems treated with monochloramine are less conducive to Legionella growth than are systems treated with chlorine, more data is needed to draw conclusions, particularly since Legionella have been found in several buildings supplied with monochloramine-treated water.

Point-of-entry (POE) treatment systems are used in some hospitals and hotels to inject chlorine dioxide or copper-silver ions into the plumbing system, or perhaps only into the hot water system.

However, this is not the most desirable or effective option for pathogen control in homes. A single treatment with chlorine or chlorine dioxide may be beneficial for newly constructed systems or systems that have been stagnant for a long period of time.

Following Water Quality Association (WQA) guidelines, the home plumbing system should also be disinfected in conjunction with the installation of a POE filtration system.

Hot water temperatures

The types of bacteria typically found in plumbing systems grow well in warm-water environments but will not multiply above a certain temperature.

For example, in the absence of biofilm, Legionella will not multiply at temperatures above 122 F (50 C) and will die within about 32 minutes at 140 F (60 C). Pseudomonas aeruginosa will not multiply above 108 F (42 C). Mycobacteria will multiply up to about 124 F (51 C).

Keeping water at 140 F (60 C) in large-building plumbing systems will not always control bacteria because of dead areas and other complexities in a large piping network, but studies have shown that high temperatures are effective in controlling Legionella bacteria in single-family residences.

In 95 Chicago-area homes studied by P.M. Arnow’s group*, Legionella were found in water samples collected from plumbing systems at temperatures under 140 F (60 C), but not in a single sample from systems above 140 F (60 C).

Setting the water heater to deliver 140 F (60 C) water to all taps will help to control waterborne pathogens but should not be done if the house is occupied by children or others who may open a hot water faucet unaware of the risk of scalding.

Skin damage will occur in adult males within 15-30 seconds at 130 F (54 C) and within 3-5 seconds at 140 F (60 C). Children and the elderly will scald even more quickly, and they will scald at lower temperatures.

Ultraviolet treatment. Properly sized ultraviolet (UV) disinfection units installed at the point of entry may be effective in controlling bacteria in home plumbing systems.

Whole-building UV has been unsuccessful in solving Legionella problems in large buildings because in those systems a residual disinfectant is required to prevent recontamination from biofilm. However, UV has been effective in controlling Legionella on a single floor of a hospital. Turbid water must be filtered for UV to be effective.

Filters and RO. Typical sediment or carbon filters will not block bacterial pathogens, and dirty ones actually make a good habitat for them. However, hollow-fiber membranes and other devices with a pore size of 0.2 micron or smaller will block bacteria.

At this time, submicron point-of-use (POU) filters are used in some hospitals but not generally in homes. However, several new sub-micron POU and POE filtration products are likely to be introduced, including products for home systems.

Whole-house hollow-fiber membrane systems, already available, provide filtration to 0.02 micron nominal and a flow rate of approximately 11 gallons per minute (gpm). These systems must be backwashed at least once daily.

Reverse osmosis (RO) systems certainly remove bacteria but need to be properly maintained to prevent bacteria growth in tanks and on membranes.

For pathogen control, filters should be evaluated based on: flow rate reduction; independent studies validating their ability to block bacteria; filter life; distance from the point of use (since bacteria could be released from biofilm downstream of the filter); and cost.

Many options are available for pathogen control in home plumbing systems, only a few of which have been discussed in this article.

Remember, it is critical to control waterborne pathogens in homes occupied by the elderly or immuno-compromised.

* “Prevalence and significance of Legionella pneumophila contamination of residential hot-tap water systems,” Journal of Infectious Diseases 152 (1985); 145-151

Matthew R. Freije is president of Solana Beach, CA-based HC Info.

He is a consultant, author and course instructor specializing in waterborne pathogens. Freije earned a B.S. degree in mechanical engineering from Purdue University; a water treatment plant operations specialist certificate from California State University, Sacramento; and is a Certified Water Specialist (WQA). His book Legionellae Control in Health Care Facilities: A Guide for Minimizing Risk has sold in more than 30 countries. Portions of this article were taken from Freije’s new book on home water treatment, due to be released this year.

High BMI Waterbirth – time for trusts to take the plunge?

Posted on 14 December 201815 September 2024 by K.D.Brainin

High BMI Waterbirth – time for trusts to take the plunge?

AIMS Journal Volume 31 No. 2 2019

Water VBAC: exploring a new frontier for women’s autonomy

Posted on 13 December 201815 September 2024 by K.D.Brainin

McKenna JA; Symon AG, (2014). Midwifery , vol 30, no 1, January 2014, e20-5.

BACKGROUND: although Vaginal Birth After Caesarean section (VBAC) has been promoted successfully as one means of reducing the caesarean section rate, the practice of VBAC using water immersion (Water VBAC) is restricted.

Very little valid, reliable research evidence is available on this birth method, although initial small-scale audits indicate that Water VBAC has no adverse effect on maternal and neonatal outcomes.

METHOD: in-depth semi-structured interviews were carried out with a purposive sample of eight women who had undergone Water VBAC in one midwife-led unit.

The interviews aimed to explore their reasons for requesting this birthing method, and their experience of the process. An interpretative phenomenological analytical approach was adopted.

FINDINGS: the women pursued Water VBAC for two main reasons: in order to prevent a repeat of the obstetric events that previously led to a caesarean section, and to counteract their previous negative birth experiences.

The women reported improved physical and psychological outcomes from their Water VBAC experience when compared with their previous experience of caesarean section.

Three main themes emerged: ‘minimising’, ‘maximising’ and ‘managing’. Water VBAC entailed an attempt to minimise the medicalisation of the women’s childbirth experience.

This was achieved by limiting medical staff input in favour of midwife-led care, which was believed to minimise negative physical and psychological experiences.

Correspondingly, Water VBAC was perceived as maximising physical and psychological benefits, and as a means of allowing women to obtain choice and assert control over their labour and birth.

The women planning a Water VBAC believed they had to manage the potential risks associated with Water VBAC, as well as manage the expectations and behaviour of friends, family and the health care professionals involved in their care.

CONCLUSIONS: for the women participating in this research, actively pursuing Water VBAC constituted a means of asserting their autonomy over the childbirth process.

The value accorded to being able to exercise choice and control over their childbearing experience was high.

These women’s accounts indicated that information-giving and shared decision-making require improvement, and that inconsistencies in the attitudes of health care professionals need to be addressed.

Nothing helps mothers cope with pain in labour more effectively

Posted on 12 December 201813 June 2026 by K.D.Brainin

Water birth pools play a vital role in helping mothers experience physiological labour and natural birth.

Nothing helps mothers cope with pain more effectively.

If mothers are not going be reliant on analgesia for pain relief they need other options.

Mothers who enter a pool of warm water in established labour find that they are better able to cope with the pain.

Immersion in warm water has been unequivocally proven to be of great benefit both physiologically and psychologically.

Women have a greater sense of fulfillment and accomplishment and babies experience a non-traumatic birth.

Aside from the obvious benefits to mothers and babies, midwives experience greater job satisfaction and hospitals save money & optimise resources.

Nearly a third of women benefited from the use of a water birth pool in the UK in 2014 (National Maternity Survey 2014).

With up to 60% of mothers open to natural birth now is the time to consider making this safe, effective, low cost option more widely available.

On land mothers contend with the force of gravity which limits movement as labour progresses and they tire.

Many women do not have the fitness to maintain upright postures for lengths of time. (Gupta JK, Hofmeyr GJ, Smyth R 2007).

Mothers who are overweight or obese are often unable to cope with the physical demands.

The transition from the land to water helps revive & energise mothers giving them a new lease on life and sense of purpose.

The buoyancy of water supports the mother reducing her relative weight by approx. 33% (Archimedes Principle).

This allows her to move in ways not possible on land.

To explore and benefit from the postures natural to labour & birth .

The calming, relaxing effect of the warm water promotes the flow of oxytocin.

This powerful hormone plays a huge role in childbirth.

It causes the uterus to contract and triggers the ‘fetal ejection reflex’.

Immersion in water has a beneficial physiological effect on hormone secretion, including oxytocin surges which can advance dilation and stimulate contractions (Odent 2014).

Excerpt from “The Waterbirth Book”: by Janet Balaskas

Posted on 8 December 201816 September 2024 by K.D.Brainin

The introduction of birthing pools in the UK began in the late 1980’s and is one of the greatest innovations to happen in natural childbirth. More than 150 hospitals in the UK now (2001) have at least one installed pool and hundreds of portable pools are also in circulation. The use of water for labour and birth is increasing and has been under intense scrutiny in the last 10 years. The outcomes of the research have so far, been positive. The help of water to enable more women to give birth naturally is very relevant at this time, when one in 5 babies in the UK is born by caesarean section.

The invigorating and therapeutic value of water is well know to all of us – from our daily bath or shower to mineral springs, saunas and spa’s, rivers, oceans – all places we go to for healing and regeneration. These qualities are brought into the labour room when we introduce a pool of warm water. This is a wonderful way to transform the atmosphere in a hospital and to encourage normal birth physiology.

Long before there was modern plumbing, water was used as a birth aid in many cultures. It’s soothing, cleansing, and healing properties were used to help women in labour and it was also used as a birth stimulant.

In New Guinea – Gahuka women gave birth by the river. The sound of the water help the mothers concentration and the flowing movement of the water helps the movement of the baby inside.
African women – Squat over steaming hot rocks to soften the perineum
Gautemalan midwives – gave women relaxing steam bath massages
Finnish women laboured in steaming saunas
Japanese women in remote fishing villages gave birth in the sea
Maories and South Pacific Islanders – Hawaiians – have oral traditions of labour and birth in water. In addition to gravity, warm water is another of nature’s elements which has enormous power to help you during your labour. It is a simple yet powerful way to relax deeply and can be the key to an easier labour.

The benefits of using a birth pool

Water is a feminine element. It is buoyant and soft and carries your body’s weight. As soon as you enter the water, the warm, sensual sensations on your skin remind you that your labouring body is beautiful, powerful, and sensual. Although this is not the case for everyone, the majority of women comment that they were surprised by how wonderful and relieving it felt when they first got into the pool.

Water pools help many women to cope better with pain and enhances those passions and deep emotions which are an integral part of a healthy birth. For many women a birth pool provides an alternative route to an epidural and can be the key to a physiological birth. The water is not likely to take away the pain, but it can make a tremendous difference to your ability to relax and may well make the pain more bearable.

Studies have shown that endorphine levels may go down in a birth pool – a sign that pain levels decrease. A birth pool is something to try before considering an epidural or other form of medical pain relief. You can always change your mind if you need to.

The buoyant effect of the water completely supports your body’s weight. This gives you a feeling of physical liberation – like being in warm ocean. Resting between contractions is much easier, because being in the water is so comfortable and relaxing. This helps tremendously to conserve your strength and energy, so you are less likely to become fatigued or exhausted.

In the pool you are in your own womblike space – you are in charge. It’s more difficult to disturb or distract you. A birth pool represents a sanctuary from what some women experience as the menace of obstetric routines. In water your body is your own territory – your birth attendants need your consent to get close to you.

The water’s buoyancy also helps enormously to make you more comfortable in upright positions. You can move more easily and spontaneously help your baby to descend and rotate by yourself.

You will be surprised to find that it’s much easier, for example, to squat in water. Even women who find squatting difficult on land, can often do so comfortably in water — with the added benefit that this position makes a lot more space in the pelvis for your baby to descend.

Once in the pool, you are unlikely to notice how much time has passed. Many women say that the world beyond the rim of the pool seems to disappear.This increased sense of privacy in the pool helps you to concentrate on working through your contractions without any distractions.

The relaxing environment helps you to let go of what is happening around you and to focus your awareness inwards on the work your body is doing and surrender to the rhythm of your labour.

The oxytocin wave – how entering a birth pool effects hormone secretion.

Water birth pioneer, Dr Michel Odent, in his latest updates on water birth, suggests that there is a correlation between the findings of physiologists on the effects of water immersion on hormone secretion and the observations of midwives that labours tend to slow down when the woman enters the pool too early.

He suggests that immediately after a woman enters the pool, there is a surge of oxytocin which stimulates contractions and results in rapid dilation. However this effect is short lived and after about 1.5 – 2 hours, oxytocin secretion reaches a peak and begins to slow down. The timing of when you enter the pool therefore becomes important.

Practical tips and guidelines

When to get in – If you are planning to use a birth pool it’s best to stay out of the water in the latent phase of labour. At this time, using upright positions, movement and breathing awareness, complementary therapies or TENS can help you to get into a comfortable rhythm with your labour (see Issue nos 8 and 10)

.In mid labour, when you are about 5 – 6 cms dilated – around the time when many women ask for pain relief – is the best time to think about entering a birth pool (our experience also shows that getting in too early can slow down contractions). Getting in late means that you are likely to be close to full dilation at the crest of the oxytocin wave.

In a long labour, contractions may slow down in the pool and then it is best get out and use the help of gravity on dry land for a while, resting in the pool later if you get tired.

The golden rule of water labour and birth – if progress is slow in water try land, if slow on land try water

The water temperature is important. Because your baby relies on you for temperature regulation and is one degree warmer than you are, the temperature of the water should never exceed 36C in labour and is best at 36C or 37C for the birth itself. When you feel cold, hormone secretion is inhibited and this will weaken your contractions. If you feel warm enough but not hot, you have probably got it just right for you. Measuring the temperature with a water thermometer is important, but don’t worry about it being too exact! How you feel is the best test.

The ideal water temperature range in labour is 32C-36C and for birth around 36C-37C

Water depth – You also need to make sure that in labour the water is deep enough to cover your belly and allow your shoulders to be exposed, so you can sweat and loose heat if you need to. Immediately after the birth there is often a need to remove some of the water, so you can breastfeed in the pool with the water keeping your baby’s body warm with his or her head out of the water at breast level.

Birthing rooms with a pool are warm and humid, so make sure that there is good ventilation and the room is not over heated. Plenty of drinking water for everyone is also a good idea, as a humid atmosphere is dehydrating.

Your partner can sit right beside you in the pool or even get in with you to massage, hold and comfort you. As you share the same environment, there is no increased risk of infection if your partner enters the pool! So it’s a good idea to have a swimsuit ready for your partner, just in case.

If this idea doesn’t appeal to you, it’s still very easy to share the intimacy of labour with your partner seated nearby, outside the pool. Having a low stool or a birth ball beside the pool is useful for your partner and for the midwife. Many women value having all the space in the pool to themselves, while others enjoy the comfort and support of relaxing against their partner’s body in the water.

* The Midwife’s practise

It is a transforming experience for a midwife to be around women in a birth pool. It is understandable that midwives contemplating their first water births may be nervous and feel insecure. Until very recently their education would not have included Water Birth. The health authority generally prefer two midwives to be at a water birth.

The fact that you are in water does not greatly change the midwife’s usual practice – in fact it makes it considerably easier, because the warm water helps you to cope better by yourself. She will need to make the normal observations of both your and your baby’s well being and the progress of your labour.

Vaginal exams can be kept to a minimum and can be done when necessary in the pool.

Monitoring the baby’s heartbeat at regular (probably half hourly) intervals is important to ensure that there is no foetal distress. However the midwife needs to be sensitive to avoid disturbing you too much – a waterproof sonic aid allows monitoring under water so you do not need to change your position or break your concentration. Alternatives are a stethoscope, a long stemmed pinnard or a regular sonic aid with the transducer in the finger of a long glove. A non water proof sonic aid may mean that you need to float close to the edge or sit up on the edge of the pool.

The midwife will check your body temperature and blood pressure at times and keep an eye on the temperature of the water.

When a birth pool is introduced into a hospital birthing room the environment is transformed into one which is much more homelike. The pool invites the mother to relax and there is usually no delivery bed in sight. The atmosphere of fear and danger are eradicated and everyone’s expectations about what will happen are different. There is a deliberate attempt to induce feelings of confidence and relaxation in the mother.

This makes a hospital environment more attractive if you want a physiological birth with the security of obstetric support close at hand. At a home birth the environment is even more ‘hormone enhancing’ when a birth pool is available and there is a powerful resource to help you cope with pain in the active stage of labour.

In the pool room it’s a good idea to dim the lights or draw the curtains to reduce stimulation so that there is a peaceful, calm and intimate atmosphere. When you can really relax in labour, as a birth pool helps you to do – you can let go more easily and things usually go well. It’s not a problem if you want or need to get out for the birth. You will have achieved the most important objective, which is a more comfortable labour, without the need for drugs or interventions.

How to use Water during Labour:
How long and When to Stay in the Water

The attraction to water and the timing of using the water pool is very individual and varies from one woman to another and one labour to another. If pre-labour contractions are intense and there are long runs of contractions prior to the onset of established labour, water can be extremely soothing.

After staying in water for some time the contractions may diminish, giving you an opportunity to rest and maybe even fall asleep, thus conserving your energy for the subsequent labour and birth.

When labour is well established, the timing of using the pool once again shows a wide individual variation. After entering the water dilation is often rapid during the first h our. It is preferable to keep the pool in reserve for the second half of labour when the contractions are intense and the periods of rest shorter.

This is when water is most powerful in assisting dilation and shortening labour. However, you might need the comfort of water from quite early on in labour and want to spend hours in the pool prior to the birth itself. In this instance you can go in and out of the pool and alternate between being in water and being on land.

When the pool is used early, mothers sometimes tire of the water and they may not want to use this valuable resource later on when contractions become more painful and intense. Getting in too early may slow down contractions and prolong labour.

Provided the correct water temperature is maintained and your temperature is monitored, it is safe to stay in the water as long as you like. The depth of the water is also important. The more your body is submerged the more help you will get from buoyancy.

However, women’s preferences vary. While some like the water to be as deep as possible, others are more comfortable in less water.

When you leave the pool it is advisable to have plenty of large towels available so that you can dry yourself completely. There should also be a heater in the room so that if you feel cold the temperature can be raised quickly.

Movements and Positions

There are bound to be times when you prefer to need to be outside the pool on dry land during your labour, for example, if labour is not progressing well in water or if you do not feel like being in water. In early labour, as your contractions are beginning to intensify it is essential to make the most of the help of gravity.

You can do this by using positions such as standing, sitting or squatting during your contractions and resting between them. Follow you instincts when moving during labour and you will find that these positions occur spontaneously.

Most women use a variety of positions. Some prefer one or two while other women are more restless and change position frequently. During contractions movements such as circling your hips or rocking your pelvis can help to dissipate the pain.

There are many ways to make yourself comfortable in upright positions so that you do not tire yourself out. It i s useful to bear in mind that the more vertical or upright your body is the more help you will get from gravity. When standing or walking you may find it helpful to lean forward onto a wall or to be held by your midwife or partner during the contractions.

When kneeling make sure your knees are resting on a soft surface and use a firm beanbag or pile of cushions to make yourself comfortable to relaxing between the contractions and to make sure that your trunk stays fairly vertical.

You may want to rest lying on your side, well propped up by cushions between contractions. For squatting, a low stool is very helpful and makes squatting less tiring. You can also hold onto a firm support or squat between your partner’s knees while he sits on a chair.

Sitting on the toilet with your knees spread apart is very comfortable in labour and for many women the privacy of the bathroom is appealing. Here you can fill the basin and splash yourself with water if you want to and enjoy the sound of running water from the tap.

Entering the Pool

Once you enter the pool, water powerfully increases your sense of privacy and adds a new dimension to the range of positions and movements you can use. The buoyancy of the water makes it much easier to move and change position and you will find that you will change positions instinctively and movement will occur spontaneously.

It’s helpful to experiment in the pool or in a swimming pool in the days before your labour begins, and to submerge your head under water at times so that you feel completely familiar and at ease in the water. This is a way to block out sounds which are distracting.

You will find that most of the movements and positions you can use on land can be used in water during contractions.

Floating between contractions is a wonderful way to relax, and wetting your hair and going under the water at times reduces outside stimulation and sounds and helps you to let go. there is a wonderful sensuous quality to being in water in labour.

It is like reconnecting with the original primal feelings you had in the womb. This is a tremendous aid to surrendering to the birth energy and to letting your body’s natural rhythms take over.

There is no need to do anything. It will help if the room is darkened and you have enough privacy. With the water as deep as possible you can use your ability to relax and quieten your mind to sink deeply into your labour.

Some women remain quite still in the water, changing positions occasionally, whereas others like to move a lot, rolling from front to back like a mermaid, or a dolphin.

Movements and position changes will happen without you needing to think about them. Between contractions you can rest and benefit from the restorative and energising properties of the water.

You can sink into its nurturing and feminine energy and accept its power to relax you. If you can let go completely you will rest, your energy will recharge and you will enter into a kind of timeless ocean of bliss between the contractions.

The End of Labour

As the birth of the baby approaches contractions will be at their most intense. They will be longer (lasting up to sixty seconds) and closer together so that the intervals are very brief.

This is the peak of labour when the ocean waves are high and turbulent, following upon each other with relentless frequency. The end of labour is usually referred to as ‘the transition stage’. You are close to full dilation and your baby’s head is about to emerge through the dilated cervix into your vagina ready to be born.

It is normal to feel fearful at this stage. This is the time when you are likely to wish you could get away or have an epidural anaesthetic, when your courage and strength may be at a very low ebb.

You may feel angry and irritable or despairing, as if you are exhausted and almost close to death. The breaks between your contractions may give you little respite before the next contraction looms large, like a tidal wave.

It is very helpful to make the most of the respite between contractions and rest and relax deeply, almost sleeping until the next wave begins. this can restore and replenish your energy surprisingly – even though the gaps are short.

The fear which is common at this stage has an important role to play. It triggers off a surge of adrenalin secretion, the ‘fight or flight’ hormone which stimulates the reflexive contractions which expel your baby during birth.

At this time you are on the threshold of giving birth. This is when the powerful demon goddess takes over as the urge to bear down and give birth arises.Outside stimulation including sound and light or touch should be minimal, as you go through these last demanding contractions without distraction.

You will be in an altered state of consciousness, deep inside your labour. Anyone who is present will need to be very discreet and avoid disturbing you, by watching, talking or by being falsely reassuring or anxious.

This time can also be difficult for birth attendants and partners who may feel an intense desire to do something to help. However, their calm silence can be a source of strength, reassurance and encouragement as you go through the intensity of the end of labour.

Some women are deeply afraid of the birth at a subconscious level and may experience difficulty in surrendering to the power of these final contractions. Being in warm water helps to let go. Often this intense phase passes very quickly or has a kind of timeless quality.

However, if transition is long, you can keep up your energy by sipping water or dilute fruit juice. Most women feel very thirsty when the adrenalin response begins and need to drink a glass or two of water. The bach flower remedy called ‘Rescue Remedy’ can be very helpful.

At this time near to the birth, the sounds emerging from the birth room tend to be loudest, so there is no need to try to be quiet. You will be in your full power, so feel free to roar like a lioness if you need to .

Noise will help you to find the power to assist your baby to come down as your body opens to give birth. Your bowels empty spontaneously as your baby’s head presses down and you may need to retch as the expulsive reflex begins.

Some women feel shy or inhibited about letting go to to these natural reflexes in the presence of other people. It helps to remember that your midwife is used to this and will welcome these events as a sign that the birth is imminent. Whatever happens your concentration will be focused deeply on the power of your contractions with moments of brief but blissful serenity in between them.

At this stage you may feel that you are almost drowning in a sea of contractions. You may wish to leave the water, or alternatively surrender to the power in the weightlessness which its buoyancy allows you.

Whether you are in or out of the pool, it is best to use the positions which feel most comfortable, making sure that you can relax, with your body supported between contractions. The water level in the pool should be as high as possible to offer you maximal support.

As birth approaches, many women prefer kneeling. This position helps to give you a sense of control over the intensity of the contractions and makes it easier to relax or even sleep in the brief intervals between them without moving or changing position.

At the very end of labour, contractions often slow down and the resting phases may lengthen. The contractions which expel our baby from the womb usually begin around the time full dilation of the cervix is reached.

In some women the urge to push may start before dilation is complete and sometimes, on the other hand, there is a break or resting period before expulsion begins. This will feel like a lull, a period of time where suddenly the waves become still and the sea becomes calm.

The lull may continue for quite a while before the pushing urge begins. On the other hand you may begin to feel the urge to bear down much earlier. Whatever happens you can trust in the wisdom of your body and surrender to its urges. Soon your baby will be born!

Giving birth in water

When you feel you are ready to push and give birth to your baby you may decide to leave the pool, to feel the solidness and security of the ground underneath you. Or you may prefer to remain in the water for the second stage. Some women have a strong urge to get out, while this possibility may not even occur to others.

In some places, especially when the midwives are new to water birth, pools are used only for labour and all women are asked to get out for the birth.

The benefits of using a pool during labour are the main reason to consider using the help of water. If you are asked to leave the pool to give birth, it is still well worth getting in for labour. The birth often happens very soon after the mother leaves the pool at the end of active labour in water.

A water birth is appropriate when labour has progressed well and when there is no sign of a potential problem during labour. When this is the case, studies have shown that giving birth in water is as safe as any other way of giving birth. A water birth is a soft and gentle way for a baby to be born and welcomed to the world.

Birth in water is a ‘low risk’ option. It is only recommended when the baby’s heart tones are strong throughout labour and second stage and when there are no complications. That’s why your midwife will want to listen in to your baby every half hour or so during labour, and this is done even more frequently in the second stage.

In places where a birth pool is encouraged as an option, women rate the experience of labour and/or birth in water very highly (one study showed that just over 90% of women who had a water birth rated it as ‘excellent’) and research has shown that fewer women need interventions.

Using a birth pool, whether just for labour or for the birth itself, is an effective and harmless way to reduce the risk of complications and to increase your chances of a natural birth.

* The dive reflex – a major discovery

The evidence of many thousands of water births all over the world has shown us that when the circumstances are appropriate, babies can be born safely into warm water at around body temperature and brought immediately to the surface to breathe. This is due to an innate reflex in human newborns called the ‘dive reflex’.

This was first discovered by the Russian researcher Igor Tjarkovsky in the 1960’s and was first described in the medical literature by the eminent neonatal physiologist Paul Johnson, from the John Radcliffe Hospital in Oxford. He is an expert on the first breathing responses of the newborn. In March 1996 he published an article ‘Birth under water- to breathe or not to breathe?’ in the British Journal of Obstetrics and Gynaecology. The dive reflex was also researched by the German obstetricians Eldering and Selke and their findings are published in the book Water Birth Unplugged.

Johnson point out that the breathing reflex in a newborn baby is stimulated at birth, at the moment when the sensory chemoreceptors around the babies nose and mouth first come into contact with air.

When the head emerges into warm water at body temperature during a water birth, this stimulation does not occur before the face emerges from the water. Under water, the dive reflex causes the air passages in the larynx to close and any water entering the nose or mouth is swallowed rather than inhaled.

The only time the dive reflex may be overridden, causing the baby to gasp under water, would be if there was severe foetal distress. This is why diligent monitoring to rule out this possibility is an essential feature of a water labour or birth. Labour and birth in water tends to minimise stress and relax the birthing mother. This in itself is a preventative of foetal distress.

However the death of a baby can occur on rare occasions with any method of birth. Infant mortality during water births that are skilfully managed, appears so far, to be exceptionally low, comparative with the national rate for low risk mothers (which is very low in the UK).

Birth in water

The possibility of your baby being born in water may be very appealing and a water birth is certainly a beautiful, gentle way to welcome your baby. However it may not be appropriate at the time, so try to avoid having too much of preconceived idea about this. Even if you would love to have a water birth, try to keep an open mind.

Water births happen when second stage progresses well and the mother does not want to leave the pool.

The baby usually emerges without difficulty, sometimes the head and body are born in one contraction. Often though, the head is born first and there is a break between contractions when just the baby’s head is out. The dive reflex is working while the head is under water, so the baby will not inhale the water. He or she is still receiving oxygen from the placenta through the umbilical cord. The placenta remains attached and working until the baby is breathing independently.

Usually with the second contraction, after the head has emerged, the shoulders and the body emerge next baby is born into the water. The buoyancy supports the baby’s body in the water and you may see the babies eyes open under water. The dive reflex is still working. The baby is then gently ‘caught’ and brought to the surface immediately.

This is done in slow motion, without rushing, within about 10 seconds after the baby has been born, which gives the baby enough time to relax and uncurl in the water on the way out. The baby is lifted out in time to take the first breath, when the mouth and nose come in contact with the atmosphere.

With this gentle way of birth, breathing usually starts slowly with the baby taking frequent little breaths instead of one big gasp. Within minutes breathing is established and it takes about 10 -15 minutes before the cord stops pulsating altogether and the transition to lung breathing is completed.

Holding your baby in your arms for the first time, is one of the most wonderful experiences you will ever know. No doubt you will kiss and caress your baby and hold him or her close to your heart. Take your time to welcome and enjoy your baby in privacy – this first bonding is the beginning of a love affair which will last a lifetime!

After the birth

While welcoming your baby you can stay in the pool and hold your baby in your arms, close to the breast. Your partner or birth attendants may need to alter the depth of the water to ensure that your baby’s body is submerged and kept warm, while the head is able to reach the breast easily above the water surface.

This is a good moment to put on a heater so the room is very warm when you leave the pool. Facilitating the first undisturbed contact between mother and baby is what is most important now – ‘daddy bonding’ time happens a little later after the placenta has emerged safely. The birth is not over until then.

While doing these practical tasks, try to keep the room very calm and quiet, maintaining privacy so that the mother is not distracted from her baby.

It’s a good idea to encourage the baby to latch on to the breast and to get the first sucking going if possible. This will stimulate more contractions. The cord is usually clamped and cut after it stops pulsating or after the placenta has emerged.

You may be asked to leave the pool when you start to get third stage contractions, so that the placenta is delivered when you are outside the pool. It’s possible to stay in the water while the placenta emerges and many experienced water birth midwives will have no objection. There is no evidence of this being a problem. However, as there is still uncertainty about this, many midwives have to adhere to a policy of the placenta being born on dry land.

The important issue now is not where the placenta emerges, but that first contact with your baby is undisturbed. So if you need to leave the pool, stand up holding your baby. Step carefully out of the pool and sit on a soft surface on the floor (an inflatable swimming ring covered by a soft towel is ideal!). Have someone drape some warm towels or a bathrobe over your shoulders and carry on welcoming and feeding your baby.

The room needs to be warm to the point of ‘over heated’ so the baby is kept very warm by your body heat and the room temperature! A soft warm towel or flannel sheet can be placed over the baby in your arms. Skin-to-skin contact with your baby should be maintained continuously, until the placenta has emerged, as this will enhance bonding and stimulate third stage contractions simultaneously.

These can feel very crampy and it is a great relief to give birth to the placenta, which is softer and smaller than a baby! It’s a surprisingly pleasurable feeling birthing the placenta.

Most women feel ecstatic after a physiological water birth. Babies tend to be calmer and often seem to smile fleetingly, although their face muscles only become strong enough to sustain a smile at around 6 weeks old. They generally settle into life easily with a sense of wholeness and continuity from the shelter of the womb to the close contact with mum after the birth. Many mother’s feel that this is the kindest, gentlest and most loving way to have a baby and that nothing could be more natural. For you and your partner it can be wonderful way to celebrate the birth of your child.

“I got into the pool at 5 cms dilated after approximately 4/5 hours of comfortable early labour at home, having used lots of movement and upright positions. Getting into the pool made me feel very comfortable and much more mobile and seemed to speed up labour. The contractions were very effective and I was fully dilated and ready to push after about 2 hours in the water. Our lovely daughter Lily Martha was delivered into the water after about 40 minutes of pushing and seemed very happy about the whole experience. I got out of the pool for a natural delivery of the placenta. I felt the whole experience of being at home and using the pool was amazing and contributed to a stress-free and wonderful natural birth.”

Melissa Clarke, London N1. First baby born 5th May 2001

Reasons to consider a water birth

Posted on 23 November 20186 November 2022 by K.D.Brainin

Bridge to Health – Sian Smith

When considering their birth plan, more and more women are choosing to include the use of water at some stage.

In fact, around 30% of women now plan to use this method either for birthing their baby or as a natural way to reduce some of the intense sensations (pain!) associated with labour.

Here are some of the reasons why:

Water is relaxing!

Being able to bob around in a large pool of warm water is the perfect environment to help you stay calm and relaxed, in a situation most would normally consider pretty stressful.

For many, sliding into a warm bath is the ‘go to’ choice of relaxation after a hard day, so what better way to help you through one of the most physically demanding and memorable experiences of your life?

Additionally, a calmer birth may be less stressful for your baby, as moving from an environment of warm amniotic fluid to one of warm water is a gentle way of introducing them to their new surroundings.

Water is a natural pain reliever

The relaxing effects of water help encourage the body to produce its own pain-fighting substances.

This is beneficial both for Mum and baby; for Mum staying relaxed helps stimulate her natural production of oxytocin (the’ love hormone’ that helps the uterus contract) and endorphins, the ‘feelgood’ hormones that help work as a natural pain reliever.

For baby, a happy and relaxed Mum is more likely to birth quickly with a reduced need for medical intervention.

It reduces stress and anxiety

It is not just the water that helps to relax you. With a waterbirth, often the entire surroundings are altered to create a calming ambience e.g. dimmed lights and hushed voices.

This enables you to go into your own world much more easily than if in a harshly lit room with strange people popping in and out.

Additionally, this type of relaxation helps encourage deep abdominal breathing, preventing you from becoming tense which may make contractions feel more intense.

It reduces the risk of perineal tearing

The warmth of the water helps to promote increased blood flow to the vagina and perineum (the area between the vagina and anus that is susceptible to tearing during childbirth).

This increases flexibility of the tissues and can reduce the likelihood of tearing when birthing the baby’s head.

It allows you to adopt a more ‘active’ birth position

A reason that some women choose a water birth is that it allows you to retain some control throughout the labour process –being aware of the contractions and sensations your body is experiencing, with a reduced chance of medical intervention.

Additionally, the sensation of ‘weightlessness’ that being in the water provides, enables you to move around much more freely than your body has allowed you to for a while!

You are free to adopt almost any position that feels comfortable for you.

The classic image of a labouring woman is that of her laying on her back with her legs in stirrups.

Whilst this is the case for many, it is actually a fairly difficult way to birth your baby as you have to work against gravity to push the baby’s head UP and over the lowest part of the spine – the coccyx.

The best way to counteract this is to work with gravity and adopt a more ‘active’ squatting or modified squatting position.

Being in the water allows you to stay in these positions for longer, as you can lean against the side of the birthing pool for support.

Remaining fit, healthy and active will also help you have as smooth a pregnancy as possible.

Your Osteopath can advise you on exercises that are suitable throughout pregnancy, specifically core, pelvic and lower limb strengthening exercises that will help you be able to adopt active birth positions and use the correct muscles to birth your baby as efficiently as possible.

It is safe!

Of course, water births are not suitable for everyone – the main criteria is that Mum and baby must be healthy, the baby must be in a head-down position, and the pregnancy must be between 37 and 42 weeks.

But as the majority of pregnancies are healthy, a water birth can offer a natural and more in control option to the labour choices a woman has.

And finally, one of the most frequently asked questions regarding waterbirths appears to be ‘will my baby drown underwater?’… to which the answer is no!

The baby receives all of its oxygen via the placenta and hormones circulating through the baby ensure this occurs until the baby is lifted out of the water.

It is also known as the ‘foetal dive reflex’ and allows babies to be underwater for short periods of time up until around 6 months old.

Exploring breech water birth

Posted on 23 November 201815 September 2024 by K.D.Brainin

Maggie Banks – RM, PhD, ADN, RGON

The paucity of literature on labour and birth in water with breech- presenting babies highlights a need to share (and document) empirical knowledge on the subject to piece together women’s and midwives’ growing experiences.

I was asked recently if leaving a woman in a birth pool to give birth to a breech presenting baby, undiagnosed until on the perineum, was ‘reasonable’ midwifery practice.

The question was qualified in that if the breech baby had been known prior to labour, the birth would definitely not have occurred in water as it is contraindicated in all the waterbirth guidelines in New Zealand.

My initial reaction, though fleeting, was to shrink away and not own my own experiences, knowing that these would be viewed as ‘unreasonable’ given that guidelines were presented as a self-evident truth that could not be argued with, that is, a known breech baby would not be born in water.

The issue of breech presentation and waterbirth is one that I have repeatedly explored in the midwifery and obstetric literature over the years and have found little written on the subject.

What is there usually cites the same source – Herman Ponette, the Belgium obstetrician in Ostend who actively promotes waterbirth with breech babies.1 There is minimal acknowledgement that it occurs in hospitals in the USA and the UK.2, 3

A Google search using the term ‘breech waterbirth’ brings up a handful of consumer stories and the occasional midwifery website which discusses the issue. Of the numerous stories I receive from women and midwives about breech birth, increasingly they involve the use of water.

This article pieces together some knowledge gained from reading, discussions, several of my experiences of, and reflections on, the use of water immersion with breech babies.

Going with the Flow

Initially I had been mindful of Michel Odent’s recommendation of not using deep warm water during breech labour as he warns that the soothing effect of water may mask an unduly painful labour, thereby preventing early detection of what may prove to be a problematic birth.4

My own first experience of using water in a breech labour happened by accident in that the frank breech baby remained undiagnosed until on the perineum. The woman had used the pool unconventionally in labour – she chose to lounge in the pool between contractions and stood during them. Once the breech was diagnosed I asked her to leave the pool and she stood to give birth.

This made me re-look at Michel’s caution. My experience of waterbirth with cephalic presentation had shown me that water immersion only mellows out normal labour pain, not severe or pathological pain, which would indicate the bone on bone painof true disproportion between pelvis and presenting part.

I had to question why this should be any different for a breech presenting baby – and I could not find an answer.

With the same woman’s second frank breech baby, this time diagnosed in pregnancy, she again used the pool unconventionally to relax between her contractions, and she birthed standing on dry land.

These two experiences marked a small shift in the use of water during my attendance at breech labour and birth in that water immersion remained available with a known breech. However, I continued to arrange with women that they would leave the pool for birthing.

This request changed following the birth of Heath, a firstborn presenting as a flexed legs breech. His mother had been deeply relaxed in the pool, assuming a wide open kneeling position leaning over the edge of the pool.

When the baby was visible on the perineum and the urge to push was overwhelming I asked the woman to leave the pool as we had prearranged, which she did.

Whereas she had been strong, independently held her own weight, and was powerful in her pushing, once out of the pool, she needed physical support to be in active birth positions and was unable to relax deeply between contractions as she had previously done in the pool.

The baby was born within half an hour of pushing and all was well but it was clear to me that I had intervened in a physiological birth and this had altered the ease with which the woman gave birth.

This birth occurred some months after the 1st International Waterbirth Conference in 1995.

Publication of Paul Johnson’s classic article 5 on the mechanisms that prevent or, conversely, stimulate breathing in the unborn baby during waterbirth would occur the following year but, in concluding his conference write up, Johnson, a Consultant Clinical Physiologist in the O&G Department at the John Radcliffe Hospital in Oxford, wrote:

“…if the onset of labour is spontaneous, and no drugs are administered, a fetus born with its cord intact, into warm, fresh water, not asphyxiated, is inhibited from breathing”6 – a process not dependant on presentation.

Initiation of breathing following waterbirth occurs once the baby surfaces and is exposed to cooler, dryer air and clamping the umbilical cord 6 – again, irrespective of presentation.

Sheila Kitzinger would report his additional comment that “if water births are of psychological and physiological benefit, it is logical that this benefit should apply to high-risk women too”.7

I knew deep water immersion to be a very powerful modality for achieving a relaxed state for the woman, enhancing vasodilation and placental perfusion and, therefore, oxygenation, of the tissues and organs, including the placenta during the normally stressing (not distressing) time of labour.

I had seen women become oblivious to everyone and everything as they sank into the pool. I had come to recognise the depth of sigh on entering the pool that signalled release of pain, fear, social etiquette and conversation – and these observations were irrespective of whether the baby was coming head or bottom first.

The Buoyancy and Warmth of Water

Another dimension was added when I attended a woman with twins, the second baby being a breech presentation. The woman had grown her babies well and began labour spontaneously at 40 weeks.

Due to the heaviness of her abdomen, she was drawn to labouring in water – her bath at home then, when labour was well established and she had travelled to her chosen birth place, the spa bath in the obstetric hospital.

There was a point in her labour where she needed to be more upright than reclining in the spa bath allowed, so we set up my free standing birth pool for her.

With the water up to the level of her breasts she became almost weightless in the pool, and was able to assume her intuitive positioning in a deep squat for the births of both her babies, the second of which had remained breech.

The woman reflected how supportive the water had been and how the upright position engaged her strength and ability to birth well.

Controlling Pelvic Pressure

When vaginal breech birth was a common occurrence 15 years or so ago, epidural anaesthesia was commonly recommended to overcome a premature urge to push. However, discussion with midwifery colleagues indicates a premature urge to push with a term breech baby is rare in woman-controlled positioning.

One woman who did experience significant pelvic pressure from the onset of labour with spontaneous rupture of membranes while having her first baby – a frank breech presentation – provided a piece to the mosaic of the use of water.

She controlled the urge to push by long and slow breathes during contractions and lying on her side on a floor mattress for most of her labour, rising only to crawl to the toilet on her hands and knees. After 12 hours of this, the pressure was overwhelming, even when lying.

While her good progress was evident from the lengthening burgundy buttock crease and her birthing energy, it was not time to use that expulsive energy. A vaginal examination confirmed a thin rim of cervix remained.

While a hands and knees position reduced the pressure, it was not until she lounged in the pool on her abdomen that the pressure again became tolerable. The pool was invaluable for enabling her to resume breathing over the contractions for the next three hours.

In the last hour prior to the birth, the woman commenced her grunting expulsions. As this had not brought her baby to a visible position in that time, I asked her to stand for one contraction to test the power of this feeling.

Simply standing engaged the pelvic pressure enough to bring the baby to almost rumping with the first push.

The second surge saw the baby rumped and progress so the popliteal spaces (back of the knees) were visible. With the next, he was born to the ankles, then descended quickly to wear his ‘perineal hat’ and his head was gently released without perineal trauma. All of this occurred without a contraction as the women responded to the pelvic pressure.

Assessing the Baby

The New Zealand Guideline Group’s best practice evidence-based guideline on breech labour and birth acknowledges that the evidence does not support continuous electronic foetal heart rate (EFM) monitoring by cardiotocography over intermittent auscultation.8

This is because, just as for well women and their babies with no alerting factors, there are no significant differences in standard measures of newborn wellbeing (including cerebral palsy and infant mortality) with continuous EFM in labour for ‘high risk’ situations, which frank or flexed legs breech presentation at term is deemed to be by some.

Only beneficial for its association with a reduced incidence of neonatal seizures, continuous EFM is associated with increased maternal morbidity by way of the accompanying increase in Caesarean and operative birth rates.9

At any given point the midwife needs to know that the baby is coping well with labour by assessment of his movements10 and listening to his heart beat.

As with any other labour for well women and babies, listening can be easily acheived with a Pinard stethoscope (or handheld, waterproof doppler) during water immersion.

Essential Elements of Physiological Breech Birth

Midwives commonly reflect on how their practice changes with attending waterbirths of cephalic presenting babies to become more ‘hands-off ’ during birth.

Confident that the water frequently dissipates urges to explosively push, while also supporting the woman’s perineal tissues and the baby as he is born, the midwife is drawn to a non touch vigilant attendance. This ‘hands off ’ in the absence of problems is the ‘golden rule’ during breech birth.

Maternal effort is an important part of achieving a ‘hands-off ’, spontaneous birth. As with any birthing, the woman needs to be supported to choose positions of comfort in the water which enhance her power and strength – kneeling, squatting, hands and knees or reclining.

Whichever birth position is chosen, the midwife needs to position herself so she can see both the advancing baby and the umbilical cord, and be in a position to palpate the umbilical cord if necessary.

The midwife may need ‘hands on’ for the birth of the head but the support of the water usually ensures gentle and woman- controlled birth of the baby’s head. Due to the reduction in gravity and an accompanying reduction in an urge to push for the head, the woman may need to be reminded to release the baby’s head.

Midwives who regularly attend waterbirths with cephalic presentation frequently reflect that if there is a problem during birth, for example, shoulder dystocia, they will initially try to correct it in the pool.

This avoids delay while utilising the water’s buoyancy so the woman can move easily to adopt very wide open positions that are needed for manoeuvres.

While Pinotte1 notes a reduced need for routine manipulations of the breech baby with waterbirth, in the rare circumstance that a manoeuvre is needed – to bring down stuck arms11 and/or flex, cradle and scoop out the baby’s head12 – these could also initially be done in the pool, again, avoiding delay.

The woman, however, would be asked to get out of the pool if problems were not easily remedied.

The Ongoing Mosaic

For some maternity professionals the issue of vaginal breech birth is no longer worth considering in the wake of the Term Breech Trial13 despite concerns about its methodological flaws.14-17

For others it remains a planned option.18-22 There will, of course, always be undiagnosed breech babies in labour, irrespective of the degree of antenatal scrutiny.

While some consider undiagnosed breech an ‘obstetric emergency’, the manner in which a midwife facilitates a vaginal breech birth, first diagnosed when birth is imminent, is the sameas if it was diagnosed antenatally and a vaginal breech birth is planned, albeit the latter having obstetric backup available with the birth in an obstetric hospital.

The use of deep water immersion with mal-presentation (read: breech) is contraindicated in hospital clinical guidelines on waterbirth, and the use of water is absent as a modality in vaginal breech birth guidelines.

Embracing these, giving birth in water to a breech baby would be out of the question for some maternity providers.

Yet others are very specific  in seeing breech presentation as a positive indication for waterbirth because of the buoyancy afforded to the baby and umbilical cord, both of which are kept warm in the water until surfacing into the cooler air,1,23,24 contraindicated only if the breech labour is not progressive and/ or is complicated.25

Midwifery can have additional knowledge fragments to obstetric knowledge, gained by our deep relationships with women.

Being attentive to women who are called to use water through breech labour and birth and walking side by side with them during this time has added to my understanding of facilitating physiological breech birth.

We need to be able to share the practice wisdom which comes from our experiences, discussions and reflections. We also need to be able to do this without fear of repercussions that may be activated from that disclosure. As a result, we will continue to find ongoing pieces to the mosaic of breech waterbirth.

References:

Ponette H. Breech and twin deliveries in the water. Accessed 20 March 2000. Available at http://www.helsinki. fi/~lauhakan/whale/waterbaby/p6.html
Kitzinger S. Sheila Kitzinger’s letter from England. Birth 1991;18(3):170–171.
Harper B. Waterbirth basics – from newborn breathing to hospital protocols. Midwifery Today 2000;54:9– 10,12–15,68.
Odent M. Birth reborn. Souvenir Press: New York, 1984:103–105.
Johnson P. Birth under water – to breathe or not to breathe. BJOG: An International Journal of Obstetrics and Gynaecology 1996;103(3):202–208.
Johnson P. Birth under water – to breathe or not to breathe. In, Lawrence Beech BA (ed).Water birth unplugged. Proceedings of the First International Water Birth Conference. Books for Midwives: Cheshire, England, 1996:31–33.
Kitzinger S. Sheila Kitzinger’s letter from England: is water birth dangerous? Birth 1995; 22(3):172–173.
New Zealand Guidelines Group. Care of women with breech presentation or previous Caesarean birth. New Zealand Guidelines Group: Wellington, 2004:xxi, 32.
Alfirevic Z, Devane D, Gyte GML. Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour. Cochrane Database of Systematic Reviews 2006, Issue 3. Art. No.: CD006066. DOI: 10.1002/14651858. CD006066.
Banks M. Utilising the unborn baby’s in-labour movements. New Zealand College of Midwives Journal 2003;29:6.
Banks M. Breech birth woman-wise. Birthspirit: Hamilton, New Zealand, 1998:88–89.
Ibid., pp. 90–91.
Hannah M, Hannah WJ, Hewson SA, Hodnett ED, Saigal S, et al. Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicenter trial. Lancet 2000;356:1375–1383.
Glezerman M. Five years to the term breech trial: the rise and fall of a randomized controlled trial. American Journal of Obstetrics and Gynecology 2006;194(1):20–25.
Kotaska A. In the literature: combating coercion: breech birth, parturient choice, and the evolution of evidence-based maternity care. Birth 2007;34(2):176–180.
Keirse MJNC. Evidence-based childbirth only for breech babies? Birth 2002;29(1):55–59.
Goer H. When research is flawed: planned vaginal birth versus elective Cesarean for breech presentation. Accessed 14 August 2007. Available at http://www.lamaze.org/ Research/WhenResearchisFlawed/ VaginalBreechBirth/tabid/167/ Default.aspx
Goffinet F, Carayol M, Foidart J, Alexander S, Uzan S, et al. Is planned vaginal delivery for breech presentation at term still an option? Results of an observational prospective survey in France and Belgium. American Journal of Obstetrics and Gynecology 2006;194(4):1002–1011.
Hellsten C, Lindqvist PG, Olofsson P. Vaginal breech delivery: is it still an option? European Journal of Obstetrics & Gynecology and Reproductive Biology 2003;111(2):122–128.
Sibony O, Luton D, Oury J, Blot P. Six hundred and ten breech versus 12,405 cephalic deliveries at term: is there any difference in the neonatal outcome? European Journal of Obstetrics & Gynecology and Reproductive Biology 2003;107(2):140–144.
Giuliani A, Schöll WMJ, Basver A, Tamussino KF. Mode of delivery and outcome of 699 term singleton breech deliveries at a single centre. American Journal of Obstetrics and Gynecology 2002;187(6):1694–1698.
van Roosmalen J, Rosendaal F. There is still room for disagreement about vaginal delivery of breech infants at term. BJOG: An International Journal of Obstetrics and Gynaecology 2002;109(9):967–969.
Charkowsky I. In: Napierala S. Water birth: a midwife’s perspective. Bergin & Garvey: London, 1994:181–182.
Enning C. Personal communication, 2008.
Ponette H. The New Aquatic Maternity in Ostend. Accessed 20 March 2000. Available at http://www.helsinki. fi/~lauhakan/whale/waterbaby/p2.html

The benefits of labouring in water for overweight and obese mothers

Posted on 23 November 20186 November 2022 by K.D.Brainin

Excerpt from article published by Big Birtha who provides information and support for bigger mums and mums to be.

All women are more buoyant and supported by water, it’s one of the reasons swimming and aqua aerobics are particularly good forms of exercise while pregnant.

But the benefit is likely to be greater for obese women, as fatter bodies are naturally more buoyant.

The buoyancy and support provided by water eases movement, which may make both maintaining an active labour and facilitating access for monitoring easier.

On land, it is cumbersome and difficult for a heavily pregnant woman of any size to quickly move between kneeling, reclining, sitting, leaning, crouching, turning from front to back etc.

In water, it is simple and easy to shift to whatever position is most comfortable/convenient, even midway through contractions.

Being in water also promotes positions which are more agreeable for birthing. Lying flat on your back on a bed is one of the worst positions to be in during labour.

When you are on your back you are working against gravity; actually trying to push the baby out uphill.

It’s only a slight incline, but it’s there.

To add to the problem, when lying down, your body weight is also resting on your coccyx (tailbone), forcing it into the pelvic cavity and reducing space for the baby.

In water, even if you were to float on your back, you wouldn’t be putting the same pressure on your tailbone, and you are far more likely to take an upright position, crouching or kneeling, for instance; positions which on land are uncomfortable to maintain, but not in water.

This frees up your coccyx to keep out of the way.

It is well documented that warm water reduces pain felt by labouring women, and decreases the use of other pain relief.

Given the issues with providing epidural anaesthesia to obese women, it seems sensible that using water; an effective non-pharmaceutical intervention to help with pain should be an attractive alternative?

Obese women are at increased risk of having longer labours, and of moving on to instrumental delivery and caesarean sections for ‘failure to progress’.

Yet immersion in water has been shown to significantly reduce the length of labour in ‘normal’ sized women.

It doesn’t take much of a leap of imagination to consider that water might help to address this problem, at least in some obese women?

BigBirtha.co.uk...

Active Birth Pools are specially designed for to accomodate bigger mothers enabling them to move and benefit from the positions natural to labour and birth.

Various means of entry and exit from the pool as well as emergency evacuation have been considered and designed for to safeguard over weight mothers and the midwives who care for them.

Clinical guidelines for a hospital water birth pool facility By Janet Balaskas

Posted on 8 November 201815 September 2024 by K.D.Brainin

Professional advice for attending midwives

1. Must be the midwives choice to help mothers in the pool room.
Two midwives present for delivery

2. Adequate education

Literature
Videos
Regular study days and conferences

3. Professional and peer support

4. Familiarity with legal implications

(in UK code of practice 3.3.3. Sections C & D).

5. Record Keeping

Annual analysis and evaluation of outcomes

6. Health and Safety

Infection control (rubber gloves – half size smaller or gauntlets, immunization)
Cleaning of the bath and equipment
Electrical safety

7. Rehearse Emergency Procedures

Ensure proximity to paediatric resuscitation and other medical aid. Familiarise procedure.

8. Midwife’s Comfort

loose-fitting clothing
theatre clothing useful

Preparation of Parents

Aqua natal and other antenatal classes

Visit to pool room – rehearsal – 34 weeks +
Review of literature – albums – photographs
Leaflets and books
Videos and discussion
Meeting other parents who have used facility

Midwife explains use of the pool

Discuss:

Expectations
Birth plan
Other forms of pain relief possible in conjunction with the pool (TNS, homoeopathy, aromatherapy).
Music, camera etc
Back-up

File notes of parent’s wishes

Parents to agree in advance

The midwife will do her utmost to facilitate the parents wishes.

However

Midwife on duty must be competent and willing

Midwife’s judgement is paramount. If the midwife is not happy about aspects of progress in the pool and wants the mother to leave the pool, she will agree to do so.

“Midwives are accountable for their own practice”

PREPARING THE POOL ROOM

Portable Pool

1. Position the pool to allow easy access all the way round (consider trolley in an emergency).

Remove all unnecessary furniture.

2. Place blue disposable liner in position

3. Run tap for five minutes before filling the pool.

Put filling pipes over the side of the pool.

Fill pool two-thirds full – temperature 36-37 degrees C

As pool is filling, adjust creases in liner.

4. Maintain temperature to mother’s comfort between 32 and 37 degrees.

With this amount of water, temperature reduces at about 1 degree per hour – check half-hourly). Keep heat retaining cover on pool when not being used.

5. Clean up any spillage – remove unnecessary hose.

6. Equipment Required

Clean sieve to remove faecal debris
Electric fan – especially in warm weather
Cassette player
Good supply of bath towels and robe
Non-slip mat
Waterproof sonic aid for monitoring or Pinnard stethoscope
Candles or essential oils, homoeopathic remedies
A large jug or cold water for drinking
Inflatable cushions, rubber ring etc.
Easy access to resuscitaire heater in room or outside
Ensure that facilities for ‘land’ birth are available in room ie: mattress or delivery bed, stool, chair, non-slip mat, beanbag.
Call system and telephone location known
Water and room thermometer, delivery pack,
Syntometrine, Lignocaine etc.

Parents’ birth plan

Admission

1. Confirm mother still wishes to use the pool

2. Base line observations

Temperature
Pulse
Blood Pressure
Urine
Palpatation – presentation and lie

3. Assess strength of contractions

4. Obtain satisfactory CTG

5. Vaginal assessment

Avoid rupture of membranes

AIM – Physiologically normal labour

6. Glycerine suppositories – some offer microlax enema (5 mls). This is not usually necessary.

7. Encourage mother too remain outside pool until mid-labour.

Use:

Aromatherapy Massage

Lavendar
Jasmine
Clary Sage

Homoeopathy

Arnica 200 (pain)
Aconite 200 (fear)
Pulsatilla 200 (weepy)
Kali Phos 200 (exhaustion)
Caulophyllum 200 (ineffectual contractions)

Labour – Inclusion criteria

Term Babies only 37 -43 weeks
Cephalic presentation established in labour
Spontaneous rupture of membranes if contracting
Induction by vaginal PGE
Good progress
Previous caesarian
Twin babies

Labour – Exclusion criteria

Foetal distress
Fresh meconium-stained liquor
Intra-uterine growth retardation
Babies at risk
Ante-partum haemorrhage
Previous post-partum haemorrhage (?)
Intravenous infusion
Severe pre-eclampsia or raised blood pressure
Epilepsy
Skin conditions
Known Hepatitis or positive HIV status
Sedation
Poor progress
Breech

Caring for the mother and baby in the pool

Labour

Priority – remember too many interruptions breaks the mother’s concentration.

Disturb as little as possible

1. Labour established prior to mother’s entry to pool (4cm onwards)

2. Mother can adopt any position she likes. Frequent changes are good.

3. Adjust depth of water for comfort

4. Lower lights

5. Midwife in constant but discrete attendance while mother is in the pool.

6. Check water temperature regularly Mother comfortable – not too warm or too cold 36-37 degrees at delivery

7. Ensure plenty of fluids – mother, partner and staff – to prevent dehydration.

8. Ventilation and room temperature to comfort.

Observations during Labour

Maternal and foetal, as usual
Maternal temperature and pulse (2 hourly)
Blood pressure (4 hourly)
Foetal heart (half hourly)
Vaginal (4 hourly, or at midwife’s discretion)
In any position Mother standing up
With partners help – float mother to surface, partner supports her under pelvis

Amniotomy

Usually unnecessary, membranes left intact as long as possible, but can be performed in water.

Pain Relief

1. Warm water may be enough

2. Breathing, visualization, relaxation techniques

3. Massage – holding – partner in pool optional (bathing trunks to be worn)

4. Homoeopathy

5. Essential oils by inhalation – Lavendar, Clary Sage or Marjoram

6. Verbal support – partner participation

7. Opitons – N20 + 02 (Entenox) – Pethidine (not to exceed 50 mgm)

Elimination

1. Inclusion of toilet in pool room preferable

2. Mother usually empties her bladder without being aware of it.

Birth in water

Exclusion Criteria

Foetal distress
Premature babies (37 –38 weeks)
Post mature babies (42 – 43 weeks)
Prolonged second stage or poor progress
Mother needs to be grounded – no power
Twins – multiple births
Breech presentation
Possible shoulder dystocia – baby large in proportion to mother
Water unusually dirty
Previous Caesarean section

Second Stage in the pool

If contractions slow down in second stage, the mother should leave the pool – if contractions are effective birth may occur under water.

Two midwives present

Second stage initiation usually self-evident. Vaginal examination not necessary as a routine.

Guidance, support – sometimes suggest different position. Do not actively encourage pushing if progress is normal. (if progress is not satisfactory – advise mother to deliver on dry land).

Crowning: manual support of perineum and control of head not usually needed, due to softening effects of water.

Baby born from front. Head delivered – with next contraction body is delivered. Slowly raise the baby to the surface of the water without delay. Baby face up under water, face down when lifted up. Mother assists or is given baby and welcomes baby with head above water but body below water to minimize heat-loss by evaporation (water level may need adjustment so mother can sit comfortably and hold baby like this)

Baby born from behind into water. Do not bring baby to surface from behind mother. Pass baby, face up, through mother’s legs and invite mother to reach down and receive the baby herself and then hold the baby’s head above, body below water surface level.

If mother stands up or baby is born above the water surface, ensure that the head does not resubmerge. Pass baby to mother (between the legs if from behind), she can then sit down in the pool with baby’s body submerged and head above the water level.

Midwife checks apex beat and cord pulsation, Apgar and blood loss observation.

Mother and father welcome baby, take photographs etc.

First sucking takes place.

Third stage in water

Exclusion Criteria:

Heavy Blood loss (> 500 mls)
Mother feels faint
Delayed delivery of placenta
Baby needs resuscitation

First contact between mother and baby undisturbed if possible.

Discreet, unhurried observations

Placenta:

In water? Out of water?
Theoretical risk of water embolism (no actual case reported).
Privacy maintained for optimal oxytocin secretion
Room temperature raised
Mother helped out of pool
Offered warm robe or towels
Baby suckling encouraged
Mother sitting upright – supported
Placenta expelled – using squatting position if necessary

A physiological third stage is logical after a natural birth.

Use oxytocic drugs only if blood loss is excessive

After delivery inspect placenta and perineum for trauma
Suturing best done one hour after leaving pool to allow recovery from the effects of saturation.
Check uterus is well-contracted and blood loss is not excessive
Leave mother comfortable with baby.

Emptying a portable pool

Place pump in the pool
Hose to suitable outlet – ensure end is securely anchored
Start pump – takes about 20 minutes
Dispose of last gallon with liner

Dealing with Emergencies

If in doubt – Get her out!

Cord around neck

No need to feel for cord after delivery of head.
If cord entanglement – loosen, slip over baby’s head or body after delivery
In rare instance of needing to cut the cord, ask mother to stand up. Once rest of the baby is delivered, mother may sit back into the pool and welcome the baby as usual.

Remember: NEVER cut the cord prior to underwater delivery

Once out of water, the baby’s head must not be allowed to resubmerge, as breathing may have initiated already.

Shoulder dystcoia

Try to exclude potential shoulder dystocia prior to onset of second stage in water.
Stand mother up out of water
Call for assistance and paediatrician
Ask mother to bend over and grip side of the pool, standing with legs well apart.
The midwife will have to step into the pool and work from behind the mother
An emergency episiotomy may have to be performed. Give traction towards mother’s back to release anterior shoulder.
In most cases of dystocia this should be effective, if shoulder in the anterior / posterior position.
If on palpation the baby feels excessively large, then perhaps it would be advisable for the mother to labour in the pool only, and deliver on dry land. Certainly ask mother to leave the pool if progress is slow with a large baby in second stage.

Episiotomy Procedure

Episiotomy is rarely needed for a water birth

Only done if baby is stuck or in an emergency where mother cannot leave the pool.

Not difficult to do in the pool

Change mother’s position – across the pool, partner supporting her shoulders
Float mother up so perineum is just under the surface (if local anaesthetic is used, ask mother to sit up on the edge of the pool for a minute or too while it is administered,
With perineum under the water surface, two fingers of left hand between head and perineum – line up scissors.
At height of next contraction – cut
Mother sinks deeper into the pool
Head delivered

Woman Collapsing in Pool
(this rarely happens if guidelines are observed)

Call for assistance.

Do not empty pool – if possible fill to maximum as buoyancy aids removal of mother from pool.

If partner is present, ask him to support woman but do not lift.

Midwife maintains airway until assistance arrives.

Assistance Arrives

State ‘Pool Emergency’ – summon further help – minimum three people, ideally four (team leader coordinates procedure.
Trolley – slide board, handling slings brought in. Tip head of trolley down and place at edge of pool. Slide board placed over edge of pool, bridging gap between pool and trolley.
Two assistants enter pool – place handling slings under woman’s chest and buttocks. Third assistant supports head.
Use buoyancy of water to float woman from pool to slide board to trolley
Dry and cover woman and escort to delivery suite if necessary, giving appropriate emergency treatment. NB: check equipment regularly.
Attend regular ‘lifting’ refresher courses with prior practice highly recommended for anyone atttending water labour or birth.

Baby slow to breathe

It has been commonly observed that babies born underwater are very calm and initiation of breathing is usually slower.
Blowing on baby’s skin stimulates breathing
Suction of air passages can be carried out with mother holding baby in the pool.
If further resuscitation is required, clamp and cut cord and take baby to resuscitaire. Clear airways and administer oxygen while summoning paediatrician. Keep warm and dry.
All midwives should attend a course on advanced neonatal resuscitation.

Please note: This is copyrighted material. But you’re free to forward it to anyone you like, as long as you don’t make any changes or profit from its use.

Manual handling risks to midwives associated with birthing pools: literature review and incident analysis

Posted on 16 October 201815 September 2024 by K.D.Brainin

Manual handling risks to midwives associated with birthing pools: literature review and incident analysis

Prepared by the Health and Safety Executive

Groundbreaking research confirms benefits of water birth

Posted on 15 October 20186 November 2022 by K.D.Brainin

Systematic review and meta-analysis to examine intrapartum interventions, and maternal and neonatal outcomes following immersion in water during labour and waterbirth

Library of Medicine

Ethel Burns¹, Claire Feeley², Priscilla J Hall³, Jennifer Vanderlaan⁴

Abstract

Objectives: Water immersion during labour using a birth pool to achieve relaxation and pain relief during the first and possibly part of the second stage of labour is an increasingly popular care option in several countries. It is used particularly by healthy women who experience a straightforward pregnancy, labour spontaneously at term gestation and plan to give birth in a midwifery led care setting. More women are also choosing to give birth in water. There is debate about the safety of intrapartum water immersion, particularly waterbirth. We synthesised the evidence that compared the effect of water immersion during labour or waterbirth on intrapartum interventions and outcomes to standard care with no water immersion. A secondary objective was to synthesise data relating to clinical care practices and birth settings that women experience who immerse in water and women who do not.

Design: Systematic review and meta-analysis.

Data sources: A search was conducted using CINAHL, Medline, Embase, BioMed Central and PsycINFO during March 2020 and was replicated in May 2021.

Eligibility criteria for selecting studies: Primary quantitative studies published in 2000 or later, examining maternal or neonatal interventions and outcomes using the birthing pool for labour and/or birth.

Data extraction and synthesis: Full-text screening was undertaken independently against inclusion/exclusion criteria in two pairs. Risk of bias assessment included review of seven domains based on the Robbins-I Risk of Bias Tool. All outcomes were summarised using an OR and 95% CI. All calculations were conducted in Comprehensive Meta-Analysis V.3, using the inverse variance method. Results of individual studies were converted to log OR and SE for synthesis. Fixed effects models were used when I² was less than 50%, otherwise random effects models were used. The fail-safe N estimates were calculated to determine the number of studies necessary to change the estimates. Begg’s test and Egger’s regression risk assessed risk of bias across studies. Trim-and-fill analysis was used to estimate the magnitude of effect of the bias. Meta-regression was completed when at least 10 studies provided data for an outcome.

Results: We included 36 studies in the review, (N=157 546 participants). Thirty-one studies were conducted in an obstetric unit setting (n=70 393), four studies were conducted in midwife led settings (n=61 385) and one study was a mixed setting (OU and homebirth) (n=25 768). Midwife led settings included planned home and freestanding midwifery unit (k=1), alongside midwifery units (k=1), planned homebirth (k=1), a freestanding midwifery unit and an alongside midwifery unit (k=1) and an alongside midwifery unit (k=1). For water immersion, 25 studies involved women who planned to have/had a waterbirth (n=151 742), seven involved water immersion for labour only (1901), three studies reported on water immersion during labour and waterbirth (n=3688) and one study was unclear about the timing of water immersion (n=215).Water immersion significantly reduced use of epidural (k=7, n=10 993; OR 0.17 95% CI 0.05 to 0.56), injected opioids (k=8, n=27 391; OR 0.22 95% CI 0.13 to 0.38), episiotomy (k=15, n=36 558; OR 0.16; 95% CI 0.10 to 0.27), maternal pain (k=8, n=1200; OR 0.24 95% CI 0.12 to 0.51) and postpartum haemorrhage (k=15, n=63 891; OR 0.69 95% CI 0.51 to 0.95). There was an increase in maternal satisfaction (k=6, n=4144; OR 1.95 95% CI 1.28 to 2.96) and odds of an intact perineum (k=17, n=59 070; OR 1.48; 95% CI 1.21 to 1.79) with water immersion. Waterbirth was associated with increased odds of cord avulsion (OR 1.94 95% CI 1.30 to 2.88), although the absolute risk remained low (4.3 per 1000 vs 1.3 per 1000). There were no differences in any other identified neonatal outcomes.

Conclusions: This review endorses previous reviews showing clear benefits resulting from intrapartum water immersion for healthy women and their newborns. While most included studies were conducted in obstetric units, to enable the identification of best practice regarding water immersion, future birthing pool research should integrate factors that are known to influence intrapartum interventions and outcomes. These include maternal parity, the care model, care practices and birth setting.

Prospero registration number: CRD42019147001.

Keywords: Maternal medicine; PRIMARY CARE; Pain management.

Research review backs benefits of water births for mothers and babies

Posted on 15 October 201815 July 2022 by K.D.Brainin

11 JULY, 2022

Nursing Times

BY STEVE FORD

Water births provide “clear benefits” over standard care for healthy mothers and their newborns, according to UK researchers.

They found water births were associated with fewer interventions and complications during and after the birth, as well as higher levels of satisfaction for the mother.

“Water immersion is an effective method to reduce pain in labour, without increasing risk”

Study authors

Researchers compared the extent of healthcare interventions needed during and after labour to see if outcomes differed between a water birth and standard care – without a birthing pool.

They noted that a water birth involves using a birthing pool to achieve relaxation and pain relief, with the mother either exiting the pool for the birth, so the newborn can emerge into air to breathe, or remaining in the pool and bringing the newborn to the surface to start breathing.

They trawled research databases looking for relevant studies published over 20 years between 2000 and 2021, finding 36 studies involving 157,546 women. Most were carried out in obstetric units.

The study results showed that a water birth, regardless of whether women birth in or out of the pool, “has clear benefits to women” in obstetric units, where most births take place and where interventions and complications are more likely than in midwife-led units.

A waterbirth was as safe as standard care for healthy mothers and their newborns, they said in the journal BMJ Open.

Compared with standard care, a water birth significantly reduced the use of epidurals, injected opioids, episiotomy, as well as pain and heavy bleeding after the birth.

In addition, it increased mothers’ satisfaction levels and the odds of an intact perineum. There was no difference in the rate of Caesarean sections, said the study authors from Oxford Brookes University.

“Water immersion can significantly increase the likelihood of an intact perineum and reduce episiotomy, an intervention which offers no perineal or foetal benefit, can increase postnatal pain, anxiety, and impact negatively on a woman’s birth experience,” they said.

However, they observed more instances of umbilical cord breakage among water births, but the rate was still low – 4.3 per 1,000 births in water compared with 1.3 per 1,000 births with standard care.

This finding may be linked to pulling on the umbilical cord when the newborn is brought up out of the water, the researchers suggested.

Overall, they stated: “Water immersion provides benefits for the mother and newborn when used in the obstetric setting, making water immersion a low-tech intervention for improving quality and satisfaction with care.

“In addition, water immersion during labour and waterbirth alter clinical practice, resulting in less augmentation, episiotomy, and requirements for pharmacological analgesia,” they said.

They concluded: “Water immersion is an effective method to reduce pain in labour, without increasing risk.”

However, they acknowledged that information on birth settings, care practices, interventions and outcomes varied considerably among the included studies, and few were carried out in midwife-led units or in the mother’s home, which may have affected the findings of the analysis.

To strengthen the evidence base, future research should include factors that are known to influence interventions and outcomes during and after labour or birth, they added.

For example, how many children a woman has already had, where she gives birth, who looks after her, and the care she receives.

“The challenge now is to ensure this choice is open to all women wherever they live”

Clare Livingstone

Commenting on the research, Clare Livingstone, professional policy advisor at the Royal College of Midwives, said: “This is really good news for women choosing to have a water birth or thinking of having one.

“There has been previous research outlining the benefits for women and this significant study adds weight to those. It is also positive because it is more information for women when deciding how they want to give birth.”

She said: “Water births are becoming more widely available for women across the UK, but this isn’t the case everywhere. The challenge now is to ensure this choice is open to all women wherever they live.”

Ms Livingstone added: “What is needed now is to see more research into water births in midwife-led settings and in women’s homes. This will give us a broader picture of the impact of water births.”

Birth under water – Michel Odent

Posted on 12 October 20186 November 2022 by K.D.Brainin

Michel Odent’s groundbreaking report “Birth Under Water” that was published in the Lancet in December 1983 is widely regarded as the seminal moment in time when the use of water for labour and birth entered our consciousness.

I’d personally like to thank Michel for being the inspiration that led me to begin to create and develop water birth pools in 1987 and for facilitating the birth of my son Theo at home in 1988.

Keith Brainin – Founder & Director Active Birth Pools

Birth under water – Michel Odent

Originally published in the Lancet: 1983

Centre Hospitalier Général de Pithiviers, PIthiviers 45300, France

The 100th birth under water in our hospital in June provided my team with an opportunity to summarise our experience of the use of water in an obstetric unit.

Since a report on birth under water in 1805,1 the subject has been rarely broached in the medical literature.

In Pithiviers, a hospital which is, in other respects, a conventional state hospital,2 a small pool has been installed close to the homely birthing room.

This pool is large enough (2m in diameter) and deep enough (about 0.7m) to make it easy for a woman in it to change her posture.

Many parturients feel and irresistible attraction to water. We don’t advise women to try the pool; we simply offer the pool as a possibility.

The water is ordinary mains tap water, at a temperature of 37 °C. The water is not sterilized, and contains no chemicals or additives on any sort.

We tend to reserve the pool for women who are experiencing especially painful contractions (lumbar pains, in particular), and where the dilation of the cervix is not progressing beyond about 5cm. In these circumstances, there is commonly a strong demand for drugs.

In most cases, the cervix becomes fully dilated within 1 or 2 hours of immersion in the pool, especially if the lights are dimmed.

It is possible to check the fetal heartbeat regularly with a small ultrasound stethoscope or with a traditional obstetrical stethoscope. Most women choose to leave the water in the second stage.

We believe that the warm pool facilitates the first stage of labour because of the reduction of the secretion of nor-adrenaline and other catecholamines; the reduction of sensory stimulation when the ears are under water; the reduction of the effects of gravity; the alteration of nervous conduction; the direct muscular stretching action; and peripheral vascular action.

Other factors, however, are difficult to rationalise. We have found, for example, that the mere sight of water and the sound of it filling the pool are sometimes sufficient stimuli to release inhibitions so that a birth may occur before the pool is full.

We have observed that water seems to help many parturients reach a certain state of consciousness where they become indifferent to what is going on around them.

Although nearly all the women who enter the pool leave it before birth, the process of delivery can sometimes be so extraordinarily fast under water, that some parturients do not leave the pool at the second stage.

Birth under water is therefore not exceptional in our unit, although it may not be intentional. During the second stage, immersion in warm water seems to help women to lose inhibitions. Most women cry out freely during the last contractions.

When the birth happens under water, the newborn infant is brought gently to the surface and placed in the mother’s arms. This is always done within seconds but without rushing (I am present at the pool for every underwater delivery).

Our experience confirms that the newborn’s first breathing is triggered by contact with the air and the sudden difference in temperature.

There is no risk of inhalation of water. It is useful to remember that in the human species carotid chemoreceptors are thought to be insensitive at birth, and very likely play no part at the time of the first cry. 3,4,5 Only 2 newborn infants out of 100 needed suction of the upper respiratory tract and a short period of manual ventilatory support.

At the time of first contact, most mothers are in a vertical position, kneeling in the water. They hold the baby in their arms in such a way that skin-to-skin and eye-to-eye contact are as perfect as possible.

An early demonstration of the rooting reflex is almost the rule, and a first sucking 20 min after the birth is common.

Water seems to facilitate the development of the mother-infant relationship. We cut the umbilical cord and help the mother leave the pool just before expulsion of the placenta.

We consider that there might be a risk of water embolism if the mother were to stay in the pool after this time. In 100 underwater deliveries there were 2 manual removals of placenta (our general rate is less than 1%).

All the presentations were cephalic. In breech presentations, our strategy is to use the first stage as a test before deciding on either a vaginal delivery or a caesarian section: in these cases we prefer not to interfere with drugs or with a bath.

Among the 100 women who gave birth underwater, there were 43 primipara, 37 secundiparas, 14 para 3, 2 para 4, one para 5, one para 6, and one para 7.

The youngest was 19 and the oldest was 43. The average age was 28. The lowest birth weight was 2.15kg and the highest was 4.40 kg, we did not perform any episiotomies.

All the tears (of which there were 29) were first degree. We had no infectious complications, even where the membranes were already broken.

There were no perinatal deaths. One infant was transferred to a paediatric unit one day after the birth with groaning and respiratory failure, symptoms which were diagnosed as subarachnoid haemorrhage after delivery in the posterior position at 37 weeks.

Only one infant was jaundiced and required phototherapy (15mg/dl bilirubin on the second day). One of the infants born under water died suddenly some weeks later, although it was previously considered to be perfectly healthy.

We have found no risk attached either to labour or to birth under water, and in any hospital where a pool is in daily use, a birth under water is bound to happen now and then.

Compared with the supported squatting position in the birthing room, we have found that the end of the second stage of labour can be more difficult under water, particularly for primipara, but immersion during the second half of the first stage of labour is helpful, particularly for parturients having painful and insufficient contractions.

It should be possible for any conventional hospital to have a pool situated close to the birthing room and operating theatre.

The use of warm water during labour requires further research, but we hope that other experience would confirm that immersion in warm water is an efficient, easy, and economical way to reduce the use of drugs and the rate of intervention in parturition.

REFERENCES

1. Embry M. Observation sur un accouchement terminé dans le bain. Ann Soc Méd Prat Montpellier 1805; 5: 13.

2. Gillett J. Chilbirth in Pithiviers, France. Lancet 1979; ii: 894-96.

3. Girard F, Lacaisse A, Dejours P. Lestimulus O 2 ventilatoire à la période néonatale chez l’homme. J Physiol (Paris) 1960; 52: 108-09.

4. Purves MJ. The effects of hypoxia in the newborn lamb before and after denervation of the carotid chemoreceptors. J Physiol 1966; 185: 60-77.

5. Purves MJ. Chemoreceptors and their reflexes with special reference to the fetus and newborn. J Devl Physiol 1981; 3: 21-57.

Birthing Pool Rules: Journal of Water Safety Forum Spring 2021

Posted on 24 September 201816 September 2024 by K.D.Brainin

Water births are largely considered safe — but are there potential microbiological risks? And what are the best recommendations to eliminate any possible dangers?

Dr Jimmy Walker clarifies some of the advice outlined in an upcoming ‘back to basics’ book* aimed at training and education on the potential microbiological risks from water in healthcare facilities.

Water births have long been considered a safe way of giving birth for women who are not expected to have complex deliveries, with the literature backing up this record to show that rates of neonatal infections are no greater in water births than conventional bed births.1,2,3,4

However, this doesn’t mean there are no risks at all. Rare instances of adverse events have occurred, including microbial neonatal infections caused by a range of organisms that have included Legionella, the cause of Legionnaires’ disease, and Pseudomonas aeruginosa — although these have largely been related to home births.

There are several routes for potential contamination of water during a water birth:

Water supply

If either of the above organisms were found in a pool, this would indicate either contamination in the water system or at the tap outlet. If only a tap outlet were colonised, the contamination may be diluted to negligible levels in the pool once that tap is run. However, running a tap when there is biofilm build-up, either in the last two metres or further back in the system, would continue to release microorganisms leading to microbial concentrations in the pool water that could lead to infections.

This is a highly unlikely scenario that would only occur if water maintenance has been neglected enough to allow conditions for microbial growth to develop: for example where pipes have not been lagged properly causing the hot water to become cooler and the cold pipe to become warmer, creating ideal temperatures to enable growth of Legionella bacteria, for example.

Bodily fluids, birthing ‘debris’ and maternal contamination

As part of the birth process, water in birthing pools will inevitably be contaminated by bodily fluids and ‘debris’, such as placenta, some of which will be caught in strainers. Pool water can also be contaminated by faecal matter and any P. aeruginosa the mother may be carrying (P. aeruginosa can occur naturally on the skin of healthy individuals), although newborns are unlikely to be at risk from maternal ‘flora’.

A clear protocol is essential for drainage of the pool, cleaning and also disinfection to remove this contamination. All accessories must also be cleaned and thoroughly disinfected — or be single use.

If contamination is not properly dealt with, then any remaining residues will encourage microbial growth that could lead to potentially dangerous contamination of the next user’s water.

Drains

The role of drains as a source of healthcare associated infections (HAIs) and potential reservoirs of antibiotic resistant organisms is now being regularly documented, with carbapenem-resistant Enterobacteriaceae (CREs) a particular concern.

Single use plugs and strainers are now most commonly used, with a large access valve for nurses and midwives to retain water in the bath. However, because birthing pools are usually located at floor level, the gradient of the drainage pipework may not be sufficient to remove the material caught in the drain. Although such an event has not yet been reported, this creates the potential for biofilmbuild-up over time, to a level that may be difficult for disinfectants to penetrate and possible contamination of the pool as soon as it is filled.

Birthing pool design

Birthing pools could be improved to prevent this backflow scenario from the drain, with designs that ensure efficient drainage of contaminating material and valves and drains that are easy to disinfect.

There are also examples of birthing pools where the pool is filled via a wall tap that enters the pool at a level where the water could flow back into the tap. This again has the potential for back contamination of the tap, with bacterial colonisation reaching even further back into the system in contravention of the water fitting directive.

Birthing pools should be designed with taps that are well above the pool’s edge and which are fitted with suitable backflow protection.

Some birthing pools also have an associated showerhead for cleaning the pool after use. However, this is also inadvisable as the flexible hose and shower head may become contaminated when they are suspended in the water. This could not only lead to backflow and contamination of the supply, but also, the contaminated hose and shower head could introduce harmful bacteria to the pool if they are not cleaned and disinfected appropriately or replaced between uses.

In addition, because water births are not always considered appropriate, there may be a prolonged period when the pool is not used. Where this is the case, a flushing regime is essential to minimise water stagnation, biofilm build-up and microbial proliferation in the water supply.

Resolving issues

Maternity units are well aware of the risks and must carry out their own risk assessments, but it is important that they are assisted in this by appropriate members of the hospitals’ water safety groups (WSGs – see p 10-12), who can provide additional specialist knowledge e.g. from microbiologists and the estates team.

Health Building Note 09-02 provides regulations and recommendations for birthing pools

References

Thoeni, A. et al “Review of 1600 water births. Does water birth increase the risk of neonatal infection?” J Matern Fetal Neonatal Med 17: 357–361, 2005. “https://doi.org/10.1080/14767050500140388″doi.org/10.1080/14767050500140388
Neiman, E. et al “Outcomes of water birth in a US hospital-based midwifery practice: A retrospective cohort study of water immersion during labour and birth”, J Midwifery Womens Health 65:216–223, 2020. “https://doi.org/10.1111/jmwh.13033″/doi.org/10.1111/jmwh.13033
Bovbjerg, M.L., Cheyney, M., Everson, C. “Maternal and newborn outcomes following waterbirth: The midwives alliance of North America statistics project, 2004 to 2009 Cohort, J Midwifery Womens Health 61:11–20, 2016. “https://doi.org/10.1111/jmwh.12394″doi.org/10.1111/jmwh.12394
4. Taylor, H. et al “Neonatal outcomes of water birth: a systematic review and meta-analysis. Arch Dis Child Fetal Neonatal 101(4):357-365, 2016. doi.org/10.1136/archdischild-2015-309600

Ventilation for the birthing environment

Posted on 26 August 201826 August 2022 by K.D.Brainin

Engineering experts Phil Nedin and Dr. Anna Coppel from Arup’s advanced Technology and Research team look at the science of ventilating a birthing room.

Water Birth Pools expel a high volume of moisture that must be considered when designing the ventilation system for a water birth room.

Ventilation for birthing pool facilities

RCM welcomes research showing benefits of water birth

Posted on 14 August 201816 September 2024 by K.D.Brainin

RCM welcomes research showing benefits of water birth

06 July 2022

RCM Maternity Services Midwifery Workforce Midwife Shortage MSWs – Maternity Support Workers Staffing Levels Waterbirth

Research showing the safety and positive benefits for women having a water birth has been welcomed by the Royal College of Midwives (RCM). The research showed that women having a water birth in a hospital obstetric unit had fewer medical interventions and complications during and after the birth.

Commenting on the research, Clare Livingstone, Professional Policy Advisor at the RCM, said: “This is really good news for women choosing to have a water birth or thinking of having one. There has been previous research outlining the benefits for women and this significant study adds weight to those. It is also positive because it is more information for women when deciding how they want to give birth.

“Water births are becoming more widely available for women across the UK, but this isn’t the case everywhere. The challenge now is to ensure this choice is open to all women wherever they live.”

The study did show a small increase in ‘umbilical cord snaps’ – where the baby’s umbilical cord breaks – though the rates remain very low. This will not hurt the baby and the midwife will respond quickly and clamp the cord to prevent any bleeding.

Clare Livingstone added, “What is needed now is to see more research into water births in midwife led settings and in women’s homes. This will give us a broader picture of the impact of water births across all the places in which women give birth.”

The research from Oxford Brookes University will be published in the open access journal BMJ Open tomorrow (6 July).

The Oxford Brookes University research can be read at https://bmjopen.bmj.com/content/12/7/e056517.full.

The Royal College of Midwives (RCM) is the only trade union and professional association dedicated to serving midwifery and the whole midwifery team.  We provide workplace advice and support, professional and clinical guidance, and information, and learning opportunities with our broad range of events, conferences, and online resources. For more information visit the RCM | A professional organisation and trade union dedicated to serving the whole midwifery team.

Giving birth in water: Low risk, high reward – study

Posted on 15 July 201815 September 2024 by K.D.Brainin

Researchers concluded that water birth is as safe as standard intrapartum care for healthy individuals, and can reduce physical pain as well as anxiety during labor.

Jerusalem Post By MAYA ZANGER-NADIS

Published: JULY 8, 2022 15:16

Water births have undeniable benefits for expectant parents and new babies, according to a study published on Tuesday in BMJ Open.

The peer-reviewed study comes out of Oxford Brookes University in the United Kingdom, in conjunction with researchers at Emory University (Georgia, US) and the University of Nevada Las Vegas (Nevada, US).

The study

For the purposes of the study, any birth that involved using a birthing pool for relaxation and pain relief was considered a water birth, even if the infant’s entrance into the world did not physically occur in the water. This is to say, those who labored in a birthing pool and then gave birth outside the pool were also counted among the data.

The team examined dozens of studies that involved over 150,000 pregnant people altogether and encompassed a wide range of birth interventions and outcomes. These included induced labor, artificial breaking of water, epidural use, C-section, episiotomy, Apgar score and NICU admittance, among many other factors.

Researchers concluded that water birth is as safe as standard intrapartum care for healthy individuals. In fact, the study showed that laboring and giving birth in a birthing pool can reduce intrapartum pain and anxiety, and decrease the risk of perineal tearing and heavy bleeding after birth.

What are the possible risks?

There has been much back-and-forth in the US-UK medical community on the safety and efficacy of water birth.

A 2006 joint statement from the United Kingdom’s Royal College of Obstetricians and Gynaecologists (RCOG) and the Royal College of Midwives (RCM) came out decidedly in favor of water birth for healthy individuals with uncomplicated pregnancies. On the other side, a 2014 article (updated 2016) published by the American College of Obstetricians and Gynecologists (ACOG) indicated that water birth may present too-high risks for:

infant aspiration (inhaling water);
possible increased risk of infection (to either parent or child);
umbilical cord avulsion (“snapping”).

Aspiration is a frightening prospect. Per the ACOG, some scientists claim that newborns usually do not inhale immediately upon exiting the womb. This could be from an innate protective “diving reflex,” or due to the fact that they must first swallow the fluids that are already in their mouth and nose before attempting to breathe.

While the July 2022 study did not go into detail on the risk of aspiration, it is only mentioned in the 2016 ACOG article as a potential issue in healthy newborns. There does not appear to be any consensus declaring that aspiration is a definite risk factor in water birth.

Infection is a broad concern that is not unique to water birth. Furthermore, it is critical to note that several recorded cases of major infection after water birth were caused by improperly prepared birthing pools with contaminated water. As is the case with any major medical event, it is critical that any and all tools must be either disposable or thoroughly cleaned before use. The RCOG/RCM statement echoed this sentiment.

Finally, the July study did state that there were more instances of umbilical cord breakages in water births than in standard care. Nevertheless, the rate was still low: 4.3/1000 births compared to 1.3/1000 births in standard care.

What is the right choice?

According to the study out of Oxford Brookes University, laboring and giving birth in a birthing pool is a decidedly low-risk, highly beneficial option for expectant parents.

The study concluded: “Water immersion provides benefits for the mother and newborn when used in the obstetric setting, making water immersion a low-tech intervention for improving quality and satisfaction with care.”

How to restore your old birth pool to pristine condition

Posted on 12 July 201827 March 2023 by K.D.Brainin

We’ve been supplying water birth pools to hospitals since 1989.

Many of the pools we supplied in the 90’s are still in active service!

Below Venus Pool at the Royal Berkshire Hospital 1992 – still in use today

We occasionally receive reports that the pools are not looking as clean and bright as they originally were.

Not to worry.

There is a product called tide mark cleaner that was developed for spas and swimming pools.

You can either use it to remove stains or brighten up the appearance of the pool when necessary.

It will restore your pool to pristine condition.

Here’s a link:

http://www.amazon.co.uk/Waterline-Cleaning-removes-lines-cleaner/dp/B006DFD7VK

For information about cleaning and disinfection procedures please click here.

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The history of Water Birth

Posted on 27 June 201815 September 2024 by K.D.Brainin

There have been accounts of women labouring and giving birth in water mostly amongst peoples living near a source of shallow warm water such as the South Pacific islanders.

In most traditional societies the rituals and practices of childbirth have, until recent times, been a matter of secrecy and handed down through generations of women.

There are oral traditions of similar practices among the Maori, the Indians of Central America, and the Ancient Greeks and Egyptians.

In 1805, the first account the use of water in Europe was documented.

A French woman, who had laboured for two days before being encouraged to get into a warm bath by her enlightened doctor then progressed to give birth to a healthy baby within an hour.

Sadly, for millions of women at the time there was no recognition of the importance of this event.

Aside from this, there are no accounts of a tradition of childbirth in water in Europe or other northerly regions.

The reason for this may be a simple matter of climate and plumbing.

Only with the widespread availability of artificially heated water and portable and installed birthing pools in comparatively recent times, has giving birth in water become a real option for women anywhere in the world.

Waterbirth was pioneered in the 1960’s by the Russian researcher Igor Tjarkovsky.

Using a large aquarium he installed a glass tank in his own home in Moscow in which many mothers gave birth .

Stunning photographs of these extraordinary births were published in the west and inspired the first water births.

For today’s generation of mothers, the key figure in the use of water for labour and birth is the French obstetrician Michel Odent.

In 1977 Odent installed a pool in the hospital at Pithiviers , not with the idea of promoting birth in water, but primarily as an additional option for pain relief and rest during long or difficult labours.

He has said ‘the reason for the birthing pool is not to have the baby born in water but to facilitate the birth process and to reduce the need for drugs and other interventions.’

Odent published his findings in the Lancet and his recommendations in this article provided the basis for the first midwifery guidelines for waterbirths.

Odent, M. Birth under water. The Lancet. December 24/31, 1983. pp 1476-1477

Inspired by news of what was happening in Moscow and France, the earliest waterbirths in the West took place at home in pools that were often improvised by the couples themselves and attended by independent midwives.

The parents created birthing pools using any large waterproof container they could find – including refuse skips, cattle troughs, inflatable paddling pools or garden ponds lined with a plastic sheet.

This happened simultaneously in several parts of the world and began to cause ripples in the world of obstetrics.

When reports and images of the first waterbirths were published, the world looked on in amazement.

The women who chose this way of birthing and their attendants were variously regarded as crazy, deluded, foolhardy or inspired.

The medical establishment rallied to condemn or at least call the practice into question, citing theoretical risks of infection and fears of the baby drowning.

Such fears have been largely appeased by the work of Dr Paul Johnson, neonatal physiologist at the John Radcliffe Hospital, Oxford.

His research on the mechanisms that trigger breathing in the newborn provided scientific confirmation of the safety of birth underwater at body temperature for babies who are not at risk.

He described how the baby is protected against the possibility of breathing while underwater in the few seconds between emerging from the birth canal and being lifted out of the water.

This response is known as the ‘dive reflex’.

Johnson, P. Birth under water – to breathe or not to breathe. British Journal of Obstetrics and Gynaecology, vol 103, no 3, March 1996. pp 202-208

In 1999 Ruth E. Gilbert and Pat A. Tookey of the Institute of Child Health, London, published a hugely important study in the BMJ that effectively provided the ‘green light’ for labour and delivery in water.

It was a study of the outcomes for all babies born in water in the UK in a two-year period between 1994 and 1996.

A total of 4,032 waterbirths were included in the study (about 0.6 per cent of all deliveries).

All 1500 consultant paediatricians in the British Isles were asked if they knew of cases of perinatal death or admission to special care within 48 hours of labour or delivery in water.

The study showed that there was no increased risk to health for babies born in water as compared with babies born to other low-risk women on land.

Since then a burgeoning of interest in the use of water in labour in the UK has led to the development of a unique concentration of knowledge and expertise within the mainstream maternity system.

Positive encouragement to the use of water in labour and childbirth has come from the Royal College of Midwives, which recommends that midwives should develop the knowledge and skills to assist women at a waterbirth .

Water labour and birth is an option which is limited to ‘low risk’ women having an uncomplicated birth following a healthy pregnancy.

In the UK the issues of safe practice have been addressed by the health authorities, Royal College of Midwives, midwifery supervisors and one or two obstetricians.

A significant body of research studies and several important surveys have been undertaken.

Development has been more carefully and diligently monitored than many of the obstetric procedures that are widely used.

Against this backdrop, more of the managers of maternity services in the UK are increasingly being persuaded that the option of using water in labour and for birth should be available to all women.

The extent of the use of birth pools in the UK increased.

Pools are now used in hospitals as well as independent birth centres, some of which specialize in waterbirths, and in the community at home births with both independent and NHS midwives.

The Edgware Birth Centre in North London is an example of a new type of forward-thinking NHS birth unit.

Typically 70 per cent of women who give birth at the centre use water during labour and 50 per cent give birth in water.

Since it’s inception outcomes show far fewer interventions than for low-risk births at a conventional hospital birth unit.

This is a model of care which would transform our maternity services if widely adopted.

In October 2000 the UK’s Royal College of Midwives estimated that 50 per cent of maternity units provided facilities for labour or birth in water.

The usage of pool varied between 15 and 60 per cent, which may be an indicator of the significance of the role of the midwife in supporting and encouraging women to consider the use of water.

Since then the number of UK hospitals and birth centres with installed pools has risen to closer to 60 per cent.

However, that does not necessarily mean that the pools are being fully or enthusiastically utilized or that the pool is always available.

It’s not uncommon for women to be discouraged from using them or to be told that trained midwives are not available.

Sometimes stringent protocols around the use of a pool can limit it’s usefulness and frustrate both mothers and midwives.

Women who want to use a pool are often also told that this may not be possible if the pool is already in use.

It’s time for such problems to be addressed and for all women to have the possibility of using a birth pool wherever they choose to give birth.

Water birth is one of the greatest innovations in childbirth of our times and can no longer be regarded as a passing fad.

The use of epidurals today has reached epidemic proportions and contributes significantly to the high caesarean and intervention rate and is also very costly, requiring a high level of expert attendance.

The simple expedient of a pool of warm water is by now a proven way to confine the use of epidurals to those women who really need them and improve safety and quality of the birth experience.

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Recessed Handgrips

Ficore® composite construction

Multi-colour LED lighting and Bluetooth® sound

Creating an Ideal Birthing Environment

Benefits for Midwives

Challenges and Considerations

The Future of Midwifery with Water Birth Pools

Conclusion

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