ACOG Rep Says Underwater Delivery Is a Bad Idea

Laura A. Stokowski, RN, MS; George A. Macones, MD, MSCE


March 27, 2014

Editor's Note:
Immersion in water during labor or delivery has been gaining in popularity in many parts of the world. Although no one knows exactly how prevalent "water birth" is in the United States, it is known that many hospitals and birth centers are equipped with tubs or are adding them to accommodate birth plan requests.

The purported benefits of immersion during the first stage of labor are reduced pain, shorter labor, and less use of anesthesia, but no evidence indicates that it improves perinatal outcomes.[1] The safety of immersion during the second stage of labor has not been established, has not been shown to benefit the mother or the fetus, and has resulted in case reports of serious adverse events in the newborn, including aspiration, drowning, infection, hyponatremia, and umbilical cord rupture, as well as death.[2]

In a joint opinion paper released this month, the American Academy of Pediatrics (AAP)[1] and the American College of Obstetricians and Gynecologists (ACOG)[3] concluded that immersion during the first stage of labor should not prevent or inhibit other elements of care, including appropriate fetal and maternal monitoring. In contrast, immersion during delivery of the neonate should be considered an experimental procedure that is performed only within the context of an appropriately designed clinical trial. The bottom line? Don't do it.

Medscape spoke with George A. Macones, MD, MSCE, who served as Chair of ACOG's Committee on Obstetric Practice while the opinion was developed. Dr. Macones is Professor and Chairman of the Department of Obstetrics and Gynecology at Washington University and Chief of Obstetrics and Gynecology at Barnes Jewish Hospital in St. Louis, Missouri.

My view is that the absence of data showing that something is safe doesn't mean that it is safe. That is a really important message in this document.

Medscape: Was there a specific reason for releasing this committee opinion now?

Dr. Macones: ACOG intermittently updates its clinical guidelines and opinions, so this was part of that process. There seems to be an increase in the number of home births in the United States, at least based on last year's data, and there is a general sense that births involving water immersion are more common in home deliveries, so that also contributed to our desire to address this issue now.

Medscape: Do we have any firm statistics on what proportion of home births involve water immersion?

Dr. Macones: No, we don't have firm numbers on it. It's a bit of an assumption, based on the number of patients we see who are transferred into our facilities.

Medscape: Where do you think the trend for immersion during labor and delivery has come from?

Dr. Macones: The popularity of at least laboring in water is regional; there are parts of the country that are really interested in it, and other areas where people are less interested. Labor tubs are actually fairly common even in hospital-based obstetrical units. I can give you an example: We are currently planning and building a new labor and delivery unit, and this was one of the big discussions that we had -- not whether we should have labor tubs for women to labor in, but how many should we have? Women seem more interested in general in having a more quiet, and perhaps natural, childbirth. I think that is part of the reason why this practice has gained some interest.

Medscape: What do the societies that authored the report hope to achieve with this opinion?

Dr. Macones: There are 3 main messages. First, overall, we don't have a lot of data about the benefits and the risks of immersion, especially underwater delivery. The second key point is that laboring in water, in a tub, as best we know, is safe and is an acceptable practice. There is some evidence (although not great) that immersion during labor might be shorter and there might be less need for regional anesthesia.

The other big message is that delivery underwater is felt to be potentially dangerous. As you read in the opinion statement, a number of cases have been reported involving serious events such as babies drowning or nearly drowning, and babies with perinatal depression related to being underwater. A very important message is that delivering a baby underwater is something to be concerned about, and providers need to know about that.

Medscape: What do we know for certain about immersion in terms of the benefits and harms?

Dr. Macones: For immersion during labor, there is some evidence, but it is not great in terms of quality, and some of it comes from countries that have very different healthcare systems from ours. Not all research is transportable across different kinds of healthcare delivery systems. The data for laboring in a tub is better than for underwater births, for which there is almost zero data.

For underwater births, what we essentially have are series of case reports of serious events that have happened, but without a denominator to tell us how often these things actually happen. My view is that the absence of data showing that something is safe doesn't mean that it is safe. That is a really important message in this document.

Medscape: The report mentions the importance of candidate selection, but no specific language is used to differentiate low-risk from higher-risk women. It also says that immersion should not preclude appropriate monitoring of the woman and fetus. Can labor be monitored during immersion?

Dr. Macones: Most people would say that laboring in water is most appropriate for women at lower risk for maternal and fetal complications during labor. There has to be some common sense and some judgment; a woman with preeclampsia or in preterm labor probably should not be laboring in a tub. If the mother is an appropriate candidate, it is possible to monitor her labor with water-immersible external fetal heart rate monitors that can be strapped to her while she is in the tub. You can monitor continuously, or intermittently, which is acceptable as well. Other types of monitoring are not possible. For example, the strength of contractions can't be monitored with an intrauterine pressure catheter, nor is it possible to put in an internal fetal scalp electrode.

Medscape: What would you tell a patient who wants to include immersion in her birth plan?

Dr. Macones: For immersion during labor, we would discuss the pros and the cons of that, and I would tell a patient that if it is something that she is interested in doing, as long as everything is going really well with her pregnancy, with her fetus and with her labor, I would be okay with that. But if there is something that we are concerned about, then we would recommend against it. If she is asking about underwater delivery, I would say absolutely not. We won't do it, and if that is something that she really wants to do, then she is going to have to find another healthcare provider to take care of her.

Medscape: Do you expect that, as a result of this statement, birth centers and hospitals will say no to delivering a baby underwater?

Dr. Macones: I certainly hope that they will say no.

Medscape: The last paragraph of the report reads, "Facilities that plan to offer immersion in the first stage need to establish rigorous protocols for candidate selection, maintenance and cleaning of tubs and pools, infection control, monitoring mothers and fetuses, and protocols for how to move the women from the tub." Do we have the evidence to support these decisions?

Dr. Macones: With that list of factors we are basically informing healthcare facilities and physicians about what we believe are the important considerations when they are developing a hospital guideline for immersion during labor. All of those are very important. You asked earlier, "How do you monitor the fetus?" Well, you have to get those monitors that work underwater; you can't use your standard fetal monitors underwater. You have to think about that upfront.

The sterilization piece is also very important. You don't want to have a mom get into a tub that hasn't been cleaned appropriately after being used with a previous laboring patient. That part of the report is focused on the idea that if a hospital or any sort of facility is going to take this on, there are important considerations they need to think about in developing their policies and procedures for laboring in water.

There is lots of room for research on many questions. For example, how long is it safe for a woman to be immersed, and when do the risks increase if a woman spends a long time in the tub?

Medscape: What have you heard from colleagues and other healthcare providers about the statement?

Dr. Macones: As obstetricians, we are very in favor of the policy as it is written. Most of us are very understanding, and I would say largely supportive, of laboring in a tub, but I do think that most people feel that delivery underwater is a dangerous practice. So, at least on the physician side, I think you are going to see broad support. In terms of nurse midwives and lay midwives, they might have a different take on the report.

Medscape: Was a nurse midwife involved in the writing process as a liaison to your practice committee?

Dr. Macones: Yes. I was Chair of the Committee on Obstetric Practice as this was being developed. It began when I was chairing the committee but wasn't finished until I had rotated off as Chair. But nursing representatives were involved, from the American College of Nurse-Midwives (ACNM) and from the Association of Women's Health, Obstetric and Neonatal Nursing (AWHONN).

Medscape: Is there anything else that you want people to know about the committee opinion?

Dr. Macones: Sometimes, when a document like this comes out, it is viewed as being not friendly to women, that we are not allowing women to have maximum choice in how they deliver. That is not the message we want to give. ACOG wants women to deliver as safely as possible and we want to do everything we can to support that. We hope that it doesn't send a negative message saying that this inhibits someone's rights to the kind of delivery they want. We want to do it safely, and that is what this is about.


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