Rapid Responses to:

CLINICAL REVIEW: Zainab Kassim, Maria Sellars, and Anne Greenough Underwater birth and neonatal respiratory distress BMJ 2005; 330: 1071-1072 [Full text]

Rapid Responses: Submit a response to this article

Rapid Responses published:

Water quality underwater birth

Chris N Hudson   (9 May 2005)

Water Birth

Andrya C Prescott   (11 May 2005)

Waterbirth case report does not constitute reliable evidence

Elizabeth Cluett, Rona McCandlish, Ethel Burns, Cheryl Nikodem   (12 May 2005)

Underwater Birth.

Stan Hammersley   (13 May 2005)

Is it water aspiration?

Martin Lalinec-Michaud   (13 May 2005)

One 'lesson of the week' may be to be careful not to misquote!

Sheila Kitzinger   (14 May 2005)

Water birth : absolute risks remain unclear

Andrew C. Breeze, Christoph C. Lees   (17 May 2005)

neonatal respiratory distress and water aspiration

Simone Rugolotto   (17 May 2005)

Water Birth-A Paediatrician's Perspective

Monika Bajaj, Richard Miles, Consultant Paediatrician, Hinchingbrooke Hospital, Huntingdon   (21 June 2005)

Water quality underwater birth 9 May 2005
Chris N Hudson, Emeritus Professor of Obstetrics n/a (formerly Barts) Send response to journal: Re: Water quality underwater birth	An instructional video of water birth with the partner also in the water, quite disingenuously showed the partner supplied with a tea- strainer "to remove solid matter from the water" Involuntary defaecation in the late second stage of labour is so common as to be unremarkable. Removal of faecal matter is ordinarily a routine aspect of midwifery care at that time.If, however, defaecation occurs into the water under which a water-birth will occur, it follows that the infant will be given its first immersion bath in water which would not meet EEC standards for "potable and recreational water". Risk Assessment and Health and Safety considerations, normally so prominent, seem to have been overlooked in this situation.It is ironic that if one of the elder siblings went to a swimming bath with this quality water there would be an outcry and it would be shut down CN Hudson Competing interests: None declared
Water Birth 11 May 2005
Andrya C Prescott, Independent Midwife Surrey Send response to journal: Re: Water Birth	I was really interested in this article. I have a caseload of approximately 20 women per year since 1999. Over 80% of my clients are considered to have one or more obstetric risk. Around 70% use water at some point in their labour and approximately 40% birth their babies in water. I have attended one case since 1999 that had a similar outcome to the baby detailed in the article. My observation and reflection was that in a case where the baby does not progress out steadily or has "sticky hips" there is a need to be hands on and assist the baby. Hips needing assistance are common in babies that fit their mothers' pelvis snugly and also in babies that lack tone. I am of course unable to draw a direct comparison with the birth detailed as there may not have been any signs visible of potential issues. There has been the odd occasion since my experience where the baby appears to lack tone once the head and shoulders are out. This appears to result in the lips parting as the mouth has no tone either. At which point I take action that would usually only necessitate assisting the baby to be born under or out of the water. Anecdotal evidence is really important when reviewing water birth as there is so little evidence available from other sources. The Independent Midwives Association is collating statistics in great detail which will be used at some point to provide further evidence regarding water birth. This information will be published at some point to expand on the current knowledge. Competing interests: None declared
Waterbirth case report does not constitute reliable evidence 12 May 2005
Elizabeth Cluett, Senior Lecturer University of Southampton, School of Midwifery. Southampton SO17 1BJ, Rona McCandlish, Ethel Burns, Cheryl Nikodem Send response to journal: Re: Waterbirth case report does not constitute reliable evidence	We were concerned and dismayed to see that the BMJ published a case report of respiratory distress for a baby born in water, citing this as evidence of the risk of waterbirth(1). Respiratory conditions can occur after any birth and in the absence of discernable antenatal fetal compromise; they are not particular to waterbirth. Billed as 'Lesson of the week' this account by two neonatologists and a radiologist from a prominent London centre is likely to provoke fear among practitioners and parents. Having recently reviewed the evidence about immersion in water during labour and birth we concluded that there was a clear need for further evidence about the safety and effectiveness of water birth(2). This systematic review provided no basis to deny this care option for women with uncomplicated pregnancy. Unfortunately this case report contributes to unreliable evidence and information women are offered when making decisions and choices for labour and birth. Safety and effectiveness of immersion in water for birth should be evaluated in a well designed randomised controlled trial. Neither opponents nor proponents serve women and babies well by continuing to accumulate anecdotal reports to support their own biases. 1.Kassim Z, Sellars M, Greenough A. Underwater birth and neonatal respiratory distress. BMJ 2005;330:1071-2 2.Cluett ER, Nikodem VC, McCandlish RE, Burns EE. Immersion in water in pregnancy, labour and birth (Cochrane Review). In: The Cochrane Library, Issue 2, 2004. Chichester, UK: John Wiley & Sons, Ltd. Competing interests: None declared
Underwater Birth. 13 May 2005
Stan Hammersley, Retired O/G Consultant. South Australia 5000 Send response to journal: Re: Underwater Birth.	The assertion that the case of respiratory distress`did not constitute reliable evidence' by the Southampton midwives ,clearly demonstrates,how little hope exists for accurate ,unbiased,scientific comment and reporting,when a group of midwives were `dismayed and concerned'at the facts published by Kassim et al. Their Case Report is quoted as `unreliable evidence' by the Southampton team. How insulting of the professional opinion, observation and fact by one team of professionals by another. Now unless my interpretation is entirely wrong, the evidence is, 1.No evidence of pre-existing fever. 2.Spontaneous rupture of membranes at term for less than 18 hours. 3 UNDERWATER BIRTH. 4. No resuscitation required. 5.Babe grunting at 1 hour. 6.Admission to NNIntensive care at 3hours with chest radiography soon after admission. This demonstrated `widespread changes consistent with aspiration of birthing pool water. As fortune had it, ,the conditions described so eloquently by Prof Chris Hudson in his previous letter on this subject did not seem to apply in this case as screening for infections was negative. How much more serious to have an E.coli or other bacterial/viral infection from birthing staff ,mother or other source,added to the existing respiratory distress. Political correctness has proceeded too far as evidenced by the critism .of a well presented and documented case. It may be more rewarding and appropriate for the Southampton team to study ways of improving `the filthy conditions' described by Prof of Obstetrics Keith Green at his hospital, and the reported infection rates throughout the British NHS, and the apalling rising maternal mortality rates in certain London hospitals,than furthering the cause of apparently dangerous birthing procedures. Thankyou for your attention. Stan Hammersley Competing interests: None declared
Is it water aspiration? 13 May 2005
Martin Lalinec-Michaud, MD Centre hospitalier universitaired de Québec, Québec Send response to journal: Re: Is it water aspiration?	I have read the case report by Sellars, Kassim and Greenhough and was left wondering if this could have been something different than water aspiration. A similar report on a child with a "regular" air birth would probably have been classified as transient tachypnea of the newborn as the story fits. As far as the radiological findings, being a general practitioner, I cannot really oppose the radiological interpretation but I have seen a few cases where baby chest radiographs are difficult to interpret as well as numerous adult's when a radiological diagnosis of pneumonia was really a cancer or cardiac insufficiency. It may be better to keep in mind that in this case, there is a possibility of water aspiration rather than jumping to firm conclusions. Competing interests: None declared
One 'lesson of the week' may be to be careful not to misquote! 14 May 2005
Sheila Kitzinger, Birth anthropologist, author of The Politics of Birth, Elsevier, 2005 The Manor, Standlake, Near Witney, Oxon OX29 7RH Send response to journal: Re: One 'lesson of the week' may be to be careful not to misquote!	I wrote, 'Babies can drown when submerged, but only if they are already severely compromised and literally at their ' last gasp' - at which point the authors omitted the rest of the sentence, 'or if they are kept under water following birth.' Water does not 'simulate' vagal receptors. It stimulates them. Competing interests: None declared
Water birth : absolute risks remain unclear 17 May 2005
Andrew C. Breeze, Clinical Research Fellow Division of Maternal-Fetal Medicine, Addenbrooke's Hospital, Cambridge, CB2 2QQ, Christoph C. Lees Send response to journal: Re: Water birth : absolute risks remain unclear	Dear Editor, Kassim et al’s lesson of the week is a useful contribution to the literature on water birth(1). Paediatricians seem at best cautious(2), and at worst hostile(3) about the practice of delivery in water. Some obstetricians appear to share these concerns(4), while others suggest it may be no more hazardous than land birth, particularly in the hands of experienced, confident birth attendants(5,6). There are still relatively few reports of severe neonatal morbidity following birth under water. Indeed, published studies from the UK and Europe do not suggest increased neonatal mortality compared to land birth(6,7), but these may be inadequately powered. It seems self-evident that there may be potential complications peculiar to water birth, and it is only right that paediatricians (and obstetricians and midwives) should be concerned about these. However, those clinicians charged with counselling women about the benefits and risks of this ‘intervention’ need high quality data about the incidence of such outcomes, and case reports unfortunately do not provide this. Such data are increasingly available on other potentially ‘high risk’ obstetric situations, such as vaginal delivery after caesarean section(8,9), vaginal breech delivery(10), and vaginal twin delivery(11). After appropriate counselling about these risks, different women will make different choices for childbirth. Until more data are available, we should counsel parents in good faith that there is an absence of evidence of safety, that complications may arise, but that with appropriate case selection, fetal monitoring in labour, and care by an experienced birth attendant, the most likely outcome is a good one – for both mother and child; fortunately severe perinatal morbidity and mortality are rare events in the context of a healthy term pregnancy. A randomised controlled trial has been suggested (12), but would appear unlikely to recruit sufficient women in an area such as this where there is often strong maternal preference for one arm or another. In the interim, there is a need for data collection by national registries of adverse outcomes in not only hospital births-but those at home and in water. Yours sincerely, Andrew C G Breeze, Clinical Research Fellow Christoph C Lees, Consultant in Obstetrics and Materno-Fetal Medicine, Division of Maternal-Fetal Medicine, Addenbrooke’s Hospital, Hills Road, Cambridge, CB2 2QQ References: 1. Kassim Z, Sellars M, Greenough A. Underwater birth and neonatal respiratory distress. BMJ 2005;330(7499):1071-1072. 2. Committee on Fetus and Newborn -, Batton DG, Blackmon LR, Adamkin DH, Bell EF, Denson SE, et al. Underwater Births. Pediatrics 2005;115(5):1413-1414. 3. Lucey JF. Editor's Note. Pediatrics 2003;112:973. 4. Grunebaum A, Chervenak FA. The baby or the bathwater: which one should be discarded? J Perinat Med 2004;32(4):306-7. 5. Brezinka C. The baby and the bathwater--a comment. J Perinat Med 2004;32(6):543-4. 6. Geissbuehler V, Stein S, Eberhard J. Waterbirths compared with landbirths: an observational study of nine years. J Perinat Med 2004;32(4):308-14. 7. Gilbert RE, Tookey PA. Perinatal mortality and morbidity among babies delivered in water: surveillance study and postal survey. BMJ 1999;319(7208):483-487. 8. Smith GC, Pell JP, Cameron AD, Dobbie R. Risk of perinatal death associated with labor after previous cesarean delivery in uncomplicated term pregnancies. JAMA 2002;287(20):2684-90. 9. Landon MB, Hauth JC, Leveno KJ, Spong CY, Leindecker S, Varner MW, et al. Maternal and Perinatal Outcomes Associated with a Trial of Labor after Prior Cesarean Delivery. N Engl J Med 2004;351(25):2581-2589. 10. Hannah ME, Hannah WJ, Hewson SA, Hodnett ED, Saigal S, Willan AR. Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Term Breech Trial Collaborative Group. Lancet 2000;356(9239):1375-83. 11. Smith GCS, Pell JP, Dobbie R. Birth order, gestational age, and risk of delivery related perinatal death in twins: retrospective cohort study. BMJ 2002;325:1004. 12. Woodward J, Kelly SM. A pilot study for a randomised controlled trial of waterbirth versus land birth. BJOG:An international journal of O&G 2004;111(6):537-545. Competing interests: None declared
neonatal respiratory distress and water aspiration 17 May 2005
Simone Rugolotto, neonatologist Neonatal Intensive Care Unit, Policlinico Hospital, University of Verona, 37134 Verona, Italy Send response to journal: Re: neonatal respiratory distress and water aspiration	Editor -- The case report by Greenough et al.(1) presents a possible neonatal complication of labouring in birthing pools. Aspiration of water has already been described in previous reports, and the outcome can range from mild neonatal respiratory distress to hypoxic ischaemic encephalopathy. Although some anecdotal reports of neonatal death are known, a 2004 Cochrane Review (number 13 in the references of the case report)(2), concluded that water birth was not dangerous, however it could not be recommended for routinely practice yet. In this review, there was no significant difference in vaginal operative deliveries, or caesarean sections, in incidence of an Apgar score less than 7 at five minutes, in neonatal unit admissions, or in neonatal infection rates. Our NICU, which is in charge of a Regional Critical Neonatal Transport Service, transported 350 neonates over the last five years. In our referral area we have a birth centre (without NICU) where birth water takes place (about 20 cases per year), and we are still waiting to transport a sick neonate born in the water! Since the chest radiograph of the neonate could be the result of amniotic fluid aspiration as well, I think that this case report cannot add evidence that water birth can be more dangerous than a caesarean section or vaginal delivery. A broncho-alveolar-lavage could be helpful to demonstrate that those patchy areas had been caused by water from birthing pool instead of amniotic fluid. In addiction, the following mild and short respiratory distress, with negative cultures, could be consistent more with amniotic fluid than water aspiration, because of the theoretical increased risk of infections and “chemical” pneumonia with aspiration of water from birthing pool. Since oxygen was delivered for nine hours only, and no positive pressure was required, the neonate could be fed regularly, which would have happened with a similar neonate with grunting flaring and retractions but not born in the water. References 1.Underwater birth and neonatal respiratory distress. Zainab Kassim, Maria Sellars and Anne Greenough BMJ 2005;330;1071-2 2.Cluett ER, Nikodem VC, McCandilish RE, Burns EE. Immersion in water in pregnancy, labour and birth. Cochrane Database Syst Rev 2004;(2):CD000111. Update of Cochrane Database Syst Rev 2000;(2):CD000111. Competing interests: None declared
Water Birth-A Paediatrician's Perspective 21 June 2005
Monika Bajaj, Specialist Registrar in Paediatrics Hinchingbrooke Hospital, Hinchingbrooke Park,Huntingdon, Cambridgeshire PE29 6NT, Richard Miles, Consultant Paediatrician, Hinchingbrooke Hospital, Huntingdon Send response to journal: Re: Water Birth-A Paediatrician's Perspective	Water Birth-a Paediatrician’s Perspective We read with interest your report of a newborn with respiratory distress after water birth (1). Recently in our hospital, a woman who was considered to have a “low risk” pregnancy was allowed to labour in water. But 1-hour later fetal bradycardia was suspected and she had to be moved out of the pool. Artificial rupture of membranes revealed blood stained liquor. She gave birth after 25 minutes (spontaneous vaginal delivery) to a baby with no signs of life. There was no maceration and given the history of all having been well just an hour earlier, full resuscitation was attempted for 50 min. Unfortunately no cardiac output could be obtained and this was classed as a stillbirth. Postmortem revealed a growth-restricted baby (2.4kg) with a horseshoe kidney and a right-sided duplex ureteric system. Notably there was evidence of a hyper-coiled umbilical cord and vasculopathy of the placenta. The combination of the latter two were thought to contribute to the acute intra-partum event. Hazards for the newborn “after” water birth are well reported (2, 3). But we did not come across any reports expressing concern regarding monitoring of labour in this setting. We wondered if this might be technically difficult and therefore detection of fetal distress might have been delayed. We also thought that the time between detection of fetal distress and decision to expedite delivery might be longer in cases of water birth in comparison to a conventional delivery. According to the Royal College of Obstetricians and our local guidelines, labour in a water birth is monitored exactly the same as a “low risk” pregnancy on dry land. A waterproof handheld Doppler instrument (sonicaid) or Pinnard’s stethoscope is used to monitor labour. Having gone through the case notes of the woman we think labour was meticulously monitored and there was nothing to suggest a delay in detection or action that followed when fetal distress was diagnosed. However we looked at the aspect of counseling of a woman choosing water birth as a mode of delivery. We found no mention of any adverse effects for the newborn in the antenatal information pack on water birth in our Trust. Although literature suggests that Perinatal Mortality is not substantially higher for water births (4), it seems that the potential for an adverse outcome for the newborn is definitely there. We believe it is important therefore to have the paediatrician’s input, informing of the possible adverse effects for the newborn in these cases. This would enable a prospective parent, to make a better-informed decision and have what all desire- a live and a healthy baby, at the end of this long and precious journey called pregnancy! (Signed consent of the patient to publication of these details has been obtained.) We have therefore taken this up as a clinical governance and risk management issue and expressed a desire that more information be given at the time of counseling in cases of water birth. Whether it is a part of the written document that is handed out with the antenatal pack or verbal counseling remains to be decided. (The patient's written consent to the publication of these details has been obtained.) References: 1. Kassim Z, Sellars M, Greenhough A. Underwater birth and respiratory distress. BMJ 2005; 330: 1071-1072. 2. Glibert R. Water Birth- A near drowning experience. Pediatrics 2002; 110(2): 409. 3. Bowden K, Kessler D, Pinette M, Wilson E. Underwater Birth-Missing the evidence or missing the point? Pediatrics 2003; 112(4): 972-73. 4. Gilbert RE, Tookey PA. Perinatal mortality and morbidity among babies delivered in water: surveillance study and postal survey. BMJ 1999;319 :483-87 Competing interests: None declared