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Water babies: Updated recommendations address laboring, delivering under water :

October 26, 2016

Immersion in water during the first stage of labor may be offered to healthy women with uncomplicated pregnancies of 37-45 weeks. But there are not enough data on the benefits and risks of “water births” to draw conclusions on this practice during the second stage of labor. Consequently, women should give birth “on land.”

These recommendations are part of an updated AAP-endorsed statement Immersion in Water During Labor and Delivery from the American College of Obstetricians and Gynecologists (ACOG).

The statement, available at, is more accepting and less judgmental of the practice of water immersion compared to the earlier (2014) version, according to Kristi L. Watterberg, M.D., FAAP. Chair of the AAP Committee on Fetus and Newborn, Dr. Watterberg is AAP liaison to the ACOG Committee on Obstetric Practice, which issued the committee opinion today.

The previous statement, a joint AAP-ACOG clinical report by the same title (, faced some criticism for its more rigid guidance. For example, the report advised that 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.”

Immersion in water during labor and delivery has become more popular over the last few decades, especially laboring in birthing tubs or pools during the early stages of labor. However, the U.S. prevalence is unknown because the practice has not been studied outside of home and birthing centers, and such data are not recorded on birth certificates.

ACOG was careful to separate its guidance on water immersion as it relates to the stages of labor, Dr. Watterberg noted.

“If you look at the effects in the first stage, one might quibble about evidence (but) nothing says it is harmful,” she said. “And several things could be beneficial — especially if the mom feels better, is more relaxed and there is decreased use of epidurals and a reduction in the duration of the first stage of labor.”

Despite the appeal, however, the statement reports there is no evidence that immersion during the first stage of labor improves perinatal outcomes.

When the actual delivery takes place in water, serious — though rare — consequences can result, including drowning or umbilical cord avulsion (snapping or rupture), as well as major infections. The statement recommends that women requesting to give birth under water should be fully informed of potential complications and the fact that the perinatal benefits and risks have not been sufficiently studied. In addition, physicians should not perform underwater deliveries if they determine, based on evidence, that they would be detrimental to the health of a woman or fetus.

When addressing the rare occasion of water aspiration, some proponents of underwater delivery maintain that infants have a “diving reflex” preventing them from breathing, gasping or swallowing water. However, in compromised fetuses and neonates, the diving reflex is overridden, according to the report, and the presence and timing of this reflex in healthy newborns also has been questioned.

Other recommendations state that facilities offering immersion during labor and delivery need rigorous protocols, including use of standard precautions and personal protective equipment. Finally, the statement’s opinion on water immersion during labor and delivery should not prevent well-designed prospective studies of the maternal and perinatal benefits and risks of these practices.

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