Obstetricians and Pediatricians Question Safety of Underwater Births

The American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics (AAP) have issued a Committee Opinion warning parents of the potential risks and complications associated with underwater births. According to the opinion, “Immersion in Water During Labor and Delivery,” ACOG and AAP reviewed existing literature regarding the “reported risks and benefits of immersion in water during labor and delivery.” However, the medical groups isolated data and outcomes for immersion during the first stage and second stage of labor in order to determine whether there are differences in outcomes. “Safety during labor may not translate into safety during delivery,” the opinion said.

Limitations of Existing Literature

“Most published literature that recommend underwater births are retrospective reviews of a single center experience, observational studies using historical controls, or personal opinions and testimonials, often in publications that are not peer reviewed,” stated ACOG and AAP. Further, there are no studies that validate the physiologic mechanisms that allegedly support the reported benefits of underwater births. The opinion also noted that existing literature fails to set forth a “uniform definition of the exposure itself,” frequently referring to immersion as “underwater birth,” as opposed to studying differences during the first and second stages of labor. In addition, the number of immersion therapies studied varied in length of immersion, depth and temperature of the water, and whether jets or whirlpool were used. Most of the trials were also small, limiting their ability to discover rare outcomes.

Proposed Benefits of Immersion

ACOG and AAP note that the proposed benefits of immersion in water during labor and delivery are inconsistent. Reported benefits included: (1) decreased pain after labor; (2) “a greater sense of well-being and control;” (3) a lower rate of perineal trauma; (4) decreased maternal stress; and (5) a “gentler” transition for newborns between in utero and ex utero environments. Although results were inconsistent, data from randomized control trials demonstrated that “immersion during the first state of labor was associated with decreased use of epidural, spinal, or paracervical analgesia among those allocated to water immersion compared with controls,” stated the opinion. There were no reported benefits to either the mother or the newborn infant from immersion during the second stage of labor and delivery.

Complications of Immersion During Labor and Delivery

Although the exact number of complications is difficult to assess, reported problems included: (1) a larger risk of maternal and neonatal infections; (2) difficulties in regulating the child’s temperature; (3) damage to the umbilical cord while the infant was maneuvered, which can lead to hemorrhage and shock; (4) respiratory distress from drowning or near drowning; and (5) seizures and post-birth asphyxia.

Conclusions

Although immersion in water during the first stage of labor has been associated with less pain, less use of anesthesia, and lower durations of labor, “there is no evidence that immersion in water during the first stage of labor otherwise improves perinatal outcomes,” stated ACOG and AAP. However, because there are no established benefits of immersion during the second stage of labor, “the practice of immersion in the second stage of labor (underwater delivery) should be considered an experimental procedure that only should be performed within the context of an appropriately designed clinical trial with informed consent,” they said.