Waterbirth fatalities

Waterbirth has become a central component of "natural" childbirth dogma, despite the fact that for primates giving birth underwater is entirely unnatural. You don't need a medical degree to appreciate the idiocy of birth in water. The most critical task for the newborn is to take its first breath. Inhaling a mouthful of fecally contaminated water instead of air is profoundly dangerous. Not surprisingly, as the popularity of waterbirth has grown, the number of neonatal deaths directly attributable to it has grown as well.

A new paper in the American Journal of Forensic Medical Pathology discusses the tragic case of a term newborn who died of Pseudomonas pneumonia and sepsis as a result of waterbirth. The authors review the existing literature on fatalities associated with waterbirth and the underlying processes leading to neonatal death.

The case report:

A normally formed 42-week gestation male infant was born underwater in a birthing tank to a 29-year-old primigravida mother. The Apgar scores were 9 and 10 at 1 and 5 minutes, respectively. The infant was covered with thick meconium and demonstrated intercostal recession with peripheral cyanosis. He was transferred to hospital where his respiratory status worsened and a chest x-ray demonstrated generalized opacity. Presumed sepsis was treated with broad-spectrum antibiotics. There was no evidence of hyponatremia. Despite maximal therapy he developed respiratory failure with disseminated intravascular coagulation and died at 4 days of age.

... Death was due to extensive P. aeruginosa pneumonia and sepsis associated with meconium aspiration and water birth.

The authors reviewed the literature:

Underwater birth has been promoted as a means of improving the quality of delivery... While the benefits of immersion are said to include increased comfort and relaxation for mother and infant, with greater maternal autonomy, fewer injuries to the birth canal, reduced need for analgesia, with decreased instrumentation and operative intervention, this has been disputed with no clear advantages or disadvantages over conventional births being demonstrated. In addition, other reports of underwater births have documented significant morbidity and even death. Problems have included infections, near drowning/drowning, hyponatremia/water intoxication, seizures, infections, respiratory distress, fevers, hypoxic brain damage, and cord rupture with hemorrhage.

Natural childbirth advocates have a terrible habit of inventing scientific "facts" and waterbirth is a classic example. According to NCB advocates, newborns will not attempt to breathe while immersed in warm water and will wait to take a first breath until they are in direct contact with air. That theory has no basis in neonatal physiology.

It has been postulated that newborns will not breath or swallow while immersed in warm water, and that respiration will only be initiated on exposure to cold air. This has been used to support assertions that drowning and aspiration of water cannot occur with underwater delivery. However, animal studies have demonstrated that this reflex can be over-ridden, and given that respiratory movements occur in utero, it is difficult to see why this process would not continue in a neonate delivered into water. The documentation of cases of near drowning and respiratory distress with apparent aspiration of fluid would also be supportive of the occurrence of breathing under water. In addition, the finding of hyponatremia in certain of these infants would be in keeping with inhalation of fresh water, as lowered sodium levels have resulted from fresh water drowning.

It is ironic that NCB advocates, the self appointed guardians of "physiologic birth" would embrace a practice that is profoundly non-physiologic. Not surprisingly, the consequences can be devastating. Neonates can and do inhale copious amounts of fecally contaminated water during waterbirth. Indeed, they have been found to inhale such large quantities of water that the water dilutes the concentration of sodium in the bloodstream to fatally low levels (hyponatremia). Even small amounts of inhaled water can introduce significant amounts of bacteria into the neonatal lungs leading to pneumonia and other infections as the authors explain:

Sepsis has also arisen from underwater deliveries, ranging from umbilical and ear infections to septicemia and pneumonia. The source of such infections has been contamination of birthing tubs, hoses, and taps with virulent organisms such as P. aeruginosa and Klebsiella pneumoniae. These bacteria have been found despite careful cleaning of systems between deliveries. Lethal Legionella infection has occurred in an underwater birth reported from Japan and other organisms such as amoeba and Mycobacterium avium have been found in spa baths...

The bottom line is that waterbirth kills babies.

As the death of a newborn from entirely preventable factors is of great concern, parents who elect to have an underwater delivery must be appraised of the risks that characterize an aquatic birth, and should have access to resuscitation equipment to enable rapid suctioning of the airway.

The avoidable tragedies of waterbirth cast a harsh light on the fundamental weakness of "natural" childbirth philosophy. "Natural" childbirth advocates pick and choose desired elements of "natural" birth without regard to whether those elements are truly natural. Despite the claims of NCB advocates that their philosophy is "evidence based," they routinely ignore scientific evidence and make recommendations without ever performing safety testing on those recommendations. Moreover, they are not above fabricating scientific "facts" to bolster claims that have no scientific support. Finally, and most egregiously, babies die as a result of their "advice" and they don't know and apparently don't care.


This piece first appeared on The Skeptical OB in May 2010.