The case for the wide-spread development of water birth facilities

In light of the publication of recent articles that report the growing demand from women around the world who want to have a natural, drug free, non-medicalised birth (Weiss 2014 and Gilbert 2015) we need to look at ways to help them have this experience.


If they are not going be reliant on analgesia for pain relief they need options to help them cope with the pain to allow a physiological labor to unfold.

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

It is not important if the baby is born in water.

In fact, water birth should be de-emphasised as it is a controversial issue in many parts of the world.

The key point and main benefit that needs to be made and focused on is how women who enter a warm pool of water in established labour with strong contractions find that they are able to cope with the pain and have a natural birth.

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 and optimise resources from the reduced use of analgesia, medical intervention and shorter hospital stays.

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 for midwives, obstetricians and hospitals to consider making this safe, low cost option available.


Studies have shown that upright labour positions are associated with a reduced second stage, fewer episiotomies or instrumental intervention in contrast to mothers labouring on their backs. (Gupta, Hofmeyr and Shehmar 2012 and Gupta and Nikodem 2000).

Many women also feel empowered in an upright position, and experience a sense of control over their labour (Balaskas 2001).

On land women need to contend with the force of gravity that limits their ability to assume upright postures especially as labour progresses and they feel tired.

Many women do not have the fitness or stamina to maintain upright postures for lengths of time. (Gupta JK, Hofmeyr GJ, Smyth R 2007).

The transition from the land to water helps revive and energise the mother giving her 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) allowing her to easily explore the full range of beneficial upright positions in comfort and move in ways that were not possible on land.


The calming, relaxing effect of the warm water promotes the flow of oxytocin, a powerful hormone that plays a huge role in childbirth, causing the uterus to contract and triggering the ‘fetal ejection reflex’.

Michel Odent has expounded upon the beneficial physiological effect that immersion in water during labour has on hormone secretion, including observations that women entering warm water experience oxytocin surges which can advance dilation and stimulate contractions (Odent 2014).

The economic impact

Studies have shown that women who are supported during labour need to have fewer painkillers, experience fewer interventions and give birth to stronger  babies.

A focus on normalising birth results in better quality, safer care for mothers and their babies with an improved experience.

Increasing normal births is associated with shorter (or no) hospital stays, fewer adverse incidents and admissions to neonatal unit  and better health outcomes for mothers.

It is also associated with higher rates of successful breastfeeding  and a more positive birth experience.

These changes benefit not only women and their families but also maternity staff.

Midwives are able to spend less time on non-clinical tasks and more on caring for women and their babies.

Psychologically speaking, and in particular for first time mothers, the less intervention and a more hands on approach with one-to-one support means that mothers will leave hospital feeling held and therefore far better prepared for motherhood.

This again has a domino effect, not just on the welfare of the infant, but also circumventing the need for costly government and interventionist approaches in particular for younger mothers post-partum.

The experience of hospitals that have birth pools demonstrates the savings  achieved through reduced use of medical methods of pain relief and shorter hospital stays.


The use of water for labour and birth – Colchester University Hospital

Feeling relaxed, secure and in control and being able to move about freely can make
it more likely for you to have a quicker and more natural birth.

For some women using a birthing pool can offer all of these benefits.

Today more and more women are considering using water for pain relief in labour.

A midwife can support you in using a birthing pool at home or in our midwife-led units
at Colchester General Hospital and Clacton and Harwich hospitals in the community.

Using a birthing pool is likely to increase the chances of a normal vaginal delivery
and therefore we would like to offer this option to as many women as possible.

We have compiled this leaflet to give you and your partner relevant information about
labouring and giving birth in water.

Please talk to your midwife during the antenatal period who will be able to answer any questions you may have.

Please click here to read the full document


Underwater birth and neonatal respiratory distress

Zainab Kassim, clinical research fellow in neonatology1, Maria Sellars, consultant in radiology2, Anne Greenough, professor of neonatology and clinical respiratory physiology

1 Department of Child Health, Guy’s, King’s and St Thomas’ School of Medicine, King’s College Hospital, London SE5 9RS, 2 Department of Radiology, King’s College Hospital, London


In 1992 the House of Commons Select Health Committee’s report on maternity services recommended that all hospitals should provide women with the “option of a birthing pool where this is practicable.

“1 A subsequent surveillance study of all NHS maternity units between 1994 and 1996 found that 0.6% of all deliveries in England and Wales occurred in water.2

Rawal and colleagues have suggested that water births have become popular among mothers and midwives because the buoyancy and warmth of the water promotes natural labour while providing a non-invasive safe and effective form of pain management.3

Practitioners and parents should remember, however, that birthing pools pose potential risks for the baby. We report on a newborn baby who developed respiratory distress due to aspiration after an underwater birth.

Case Report

A full term male infant weighing 3150 g was born in the birthing pool of the labour ward of our hospital. His mother was a 34 year old, healthy primigravida who had had an uneventful pregnancy.

She had gone into spontaneous labour at 40 weeks’ gestation and had had no maternal fever during labour; at delivery the membranes had been ruptured for less than 18 hours. The baby was born underwater.

He required no resuscitation but, when reviewed at one hour, was grunting. As the grunting persisted, he was admitted to the neonatal intensive care unit at 3 hours of age. He had no fever but was tachypnoeic and had intercostal recession and nasal flaring.

He needed supplementary oxygen to maintain his oxygen saturation level at 92%; his need for supplementary oxygen persisted for nine hours. He was screened for infection and started on antibiotics (benzylpenicillin and gentamicin).

In view of his respiratory distress, which persisted for 48 hours, he was designated “nil by mouth” and fluid was administered intravenously until he had recovered. Chest radiography soon after admission showed widespread changes consistent with aspiration of the birthing pool water (figure).

Further radiography, on day 3, showed resolution of the abnormalities, and the infection screen was negative. The infant made a full recovery and, when seen as an outpatient at age 3 months, was free of symptoms.


Some researchers have suggested that “babies can only drown when submerged, only if they are already severely compromised and literally at their `last gasp,’ as water simulates vagal inspiration receptors causing glottic closure.”4

In lambs, however, inhibitory mechanisms that prevent breathing until the lamb is in contact with cold air can be overridden by sustained hypoxia.5

Likewise, in a birthing pool, some babies with unrecognised hypoxia may gasp underwater. Indeed, the 1994 to 1996 survey cited two reports of water aspiration,2 and similar cases have been documented in the literature.6-8

Our case report emphasises the adverse effects of aspiration of water in birthing pools. Although such events seem uncommon, this may be the result of under-reporting.

Respiratory distress immediately after birth is common and has various aetiologies. Thus, unless a careful history is taken, the cause the respiratory distress may be misdiagnosed.9

We are confident that the case we report was due to aspiration of water as the infant developed symptoms soon after birth, with resolution by 48 hours.

In addition, there were no risk factors for infection or indeed any bacterial infection identified. Infection after water birth has been described.10-12

The baby in our case report was delivered after spontaneous labour at term, making transient tachypnoea of the newborn unlikely; indeed, the chest radiograph was consistent not with that diagnosis but with aspiration.

A systemic review of randomised trials has shown that immersion during labour is associated with significant reductions in the use of epidural, spinal, or paracervical analgesia and in women’s reports of pain, but highlighted there were insufficient data to determine the outcome from randomised trials of birth in water for women or their infants.13

In addition to water aspiration and subsequent pulmonary oedema,8 however, other adverse neonatal outcomes after water birth have been reported; these include water intoxication, hyponatraemia, hypoxic ischaemic encephalopathy, cord rupture with neonatal haemorrhage, and pneumonia.12 14

Women who have water births are usually considered to be “low risk,” and so they and their infants should have an excellent prognosis. Our case report and review of the literature confirm that water birth has risks for the newborn.

Practitioners and parents need to be aware of these potential risks so that mothers can make a fully informed decision about place of delivery.

Water birth can be associated with adverse effects in the newborn

Contributors: ZKand AG collected the clinical data, and MS col- lected the radiographic data. All authors contributed to writing the paper, and AG is the guarantor.

Funding: No special funding. Competing interests: None declared.


      1. House of Commons Health Select Committee. Maternity services. Second report. London: HMSO, 1992.
      2. Ruth E, Gilbert P, Tookey A. Prenatal mortality and morbidity among babies delivered in water: surveillance study and postal survey. BMJ 1999;319: 483- 7.
      3. Rawal J, Shah A, Stirk F, Mehtar S. Water birth and infection in babies. BMJ 1994;309: 511-2.
      4. Kitzinger S. Sheila Kitzinger’s letter from Europe: the waterbirth debate up-to- date. Birth 2000;27: 214-6.
      5. Johnson P. To breathe or not to breathe. Br J Obstet Gynaecol 1996; 103: 202- 3.
      6. Rosser J. Is water birth safe? The facts behind the controversy. MIDIRS Midwifery Digest 1994;4: 4-6.
      7. Barry CN. Water births. Could saline in the pool reduce the potential hazards? BMJ 1995;310: 1602.
      8. Nguyen S, Kuschel C, Teele R, Spooner C. Water birth—a near-drowning experience. Pediatrics 2002;110: 411-3.
      9. Bowden K, Kessler D, Pinette M, Wilson E. Underwater birth: missing the evidence or missing the point? Pediatrics 2003;112: 972-3.
      10. Rawal J, Shah A, Stirk F, Mehtar S. Water birth and infection in babies. BMJ 1994;309: 511.
      11. Nagai T, Sobajima H, Iwasa M, Tsuzuki T, Kura F, Amemura-Maekawa J, et al. Neonatal sudden death due to Legionella pneumonia associated with water birth in a domestic spa bath. J Clin Microbiol 2003:41: 2227-9.
      12. Pinette MG, Wax J, Wilson E. The risks of underwater birth. Am J Obstet Gynecol 2004;190: 1211-5.
      13. Cluett ER, Nikodem VC, McCandilish RE, Burns EE. Immersion in water in pregnancy, labour and birth. Cochrane Database Syst Rev 2005;(1)
      14. Schroeter K. Water births: a naked emperor. Pediatrics 2004;114: 855-8.

(Accepted 16 March 2005)

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