Underwater birth and neonatal respiratory distress
BMJ 2005; 330 doi: https://doi.org/10.1136/bmj.330.7499.1071 (Published 05 May 2005) Cite this as: BMJ 2005;330:1071
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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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests