Water Birth

I’m a big fan of water birth for plus-size women and birthing people. Being denied a pool because of my size is one of the main reasons this website even exists!

What is water birth?

‘Water birth’ can mean either labouring or giving birth while immersed in water. Or both! Although often assumed to be a ‘new’ idea, water has been used in this way for centuries. We didn’t need the invention of purpose-designed pools to take advantage of water’s soothing properties!

It is easy to see how and why. Many people experimenting with managing period pains find that lying in a warm bath helps to soothe the spasms. Labour pains often begin in a similar fashion, and for many of us, a bath helps with those too. A birth pool is merely a larger, deeper bath which facilitates full immersion even when seated. Domestic baths are great in the early stages of labour, but they’re generally not deep enough or wide enough. A birth pool allows the greater flexibility of movement a labouring person is likely to need to remain comfortable.

Where?

Birthing pools are similar in size to a hot tub, but with no jets. Often they have steps, built-in seats, and handrails to grab onto, even the inflatable ones!

Most UK maternity hospitals and midwife led delivery units now have access to a birthing pool. For many, this is a permanent fixture in at least one delivery room.

Alternatively, or often in addition to permanent pools, some maternity services also have inflatable, multi-use birthing pools. These offer the flexibility of being moved to different rooms and potentially loaned out for use in the community.

Lastly, there is always the option to have a birthing pool at home. There are various models available, in a range of sizes, some inflatable, some with hard sides, some have disposable liners. Some even come with their own heating element and thermostatic controls! (just don’t fill them up in advance, due to the risk of Legionnaire’s disease).

If you don’t want to or can’t afford to buy your own pool, don’t worry! Google local companies, charities, and health services who hire them out.

Why?

Research has shown that using water during labour reduces the amount of pain reported, resulting in a reduction other forms of pain relief; shorter labour durations; and increased satisfaction for the user.

This was certainly true in my case. The intensity of my contractions whenever I left the warmth and comfort of the water astonished me! Contractions that had been perfectly bearable were suddenly much stronger and harder to manage. I made sure to get back in as soon as possible.

There is no evidence of negative impact to the baby from either labouring or birthing in water. Babies are immersed in liquid already when inside our tummies, being born through water is merely an extension of this. There is no evidence of any increase in neonatal infections, reduction in apgar scores, or any other measure by which it would seem to be a disadvantage to the baby.

It’s important to be aware that pools should not be filled in advance of labour, due to the risk of Legionnaire’s disease. Legionnaire’s is a serious lung infection, caused by legionella bacteria. For more information, read the Water Birthing Pools and Legionnaires Risk page.

When?

Water can be used at any stage in labour, though its use is more common in the early stages. Many of those who labour in water are comfortable giving birth in water, others prefer to do so on dry land.

It is not uncommon to change your mind about where you want to give birth during labour itself! Even if you’ve had strong opinions about it beforehand, it is often not possible to know your real preference until the time comes. What is most important is what matters to you at the time.

You will need to leave the pool, particularly to visit the toilet, as it’s advisable to empty your bladder regularly. This ensures the maximum possible space available in the birth canal. Your midwife may ask you to leave to check progress, but with waterproof equipment, this is becoming less necessary. There are waterproof dopplers for monitoring the baby’s heart rate etc.

Who?

If your BMI is over 35, you may have difficulties finding a service which allows you to use their pool. Some maternity settings have a sensible case by case, individualised risk assessment approach. Others have a blanket ‘no women with a BMI of 35+’ approach. The only way to find out is to check.

• Just because you know the delivery suite has a pool, and you’re booked in there, DON’T ASSUME you can use the pool!
• If you say you want a water birth at your antenatal appointments and in your birth plan, and no-one says you can’t, DON’T ASSUME you’ll be allowed to use the pool!
• Even if you had a water birth with that Hospital Trust previously, DON’T ASSUME you’ll be allowed to use the pool!

I made the first two mistakes in my first pregnancy. I was furious when I discovered at 8cm dilated that I was denied access. Don’t make my mistake! Submit a freedom of information request as early in your pregnancy as you can so you know what the sticking points might be. Find out how many water births have actually taken place in your chosen birth location – and were any of them people with a similar BMI? Individual hospital policies can be found here – if you request yours, please do let me know and I’ll add them!

Why not?

There is no evidence to suggest that labouring or birthing in water is unsafe for bigger people.

That’s because there is no evidence on bigger people using birth pools full stop. All evidence refers only to ‘low-risk’ pregnancies. We are no more able to declare plus-size water birth unsafe than we are able to say it’s more safe. There is no evidence either way.

However, reasons some hospitals give when barring access on the grounds of BMI are:

Health and Safety

Surprise! Everyone’s favourite reason for denying everything. If you collapsed, it would apparently be an issue for staff trying to get you out of the pool.

Ironically, hospitals which say this often don’t prevent you from using their baths while in labour!? These are usually in much more cramped surroundings, and don’t offer the usual 360° access of a birth pool?!

There are plenty of options to counter this argument – please read further below!

Shoulder dystocia

You will often hear that shoulder dystocia (where the baby’s head is born, but the shoulders get stuck) is more common in bigger people. But this is another case where researchers have assumed all people with similar BMIs share the same characteristics. People with higher BMIs are more likely to have other health complaints (or rather, perhaps, people with other health complaints are more likely to have higher BMIs!)… and those other conditions are also more highly correlated with incidences of shoulder dystocia.

Research has shown that higher BMI people with no other conditions are no more likely to experience shoulder dystocia than someone ‘normal’ sized (I hate that term!!). The number of births with shoulder dystocia are so small (less than half a percent), it is difficult to get enough data to get an accurate picture.

Given that the primary course of action in cases of shoulder dystocia is for the labouring person to change position, water may even help! The buoyancy provided by water gives us greater freedom of movement to change position. With this support, it is easier to widen the pelvis, making it more likely that the shoulders can be born.

High blood pressure

There can be a concern that people with a higher BMI, who are more likely to have high blood pressure, could collapse in a pool. Obviously, collapsing in a pool is not good. But we can check blood pressure, easily! Not everyone with a high BMI has high blood pressure, so it is nonsense to ban plus-size water birth on these grounds. Ironically, immersion in water is associated with lowering blood pressure, as it has a calming effect!

Certain ethnic groups are prone to higher blood pressure, but I’d be surprised if any hospital used ethnic profiling to restrict access to birthing pools. A blanket restriction of birth pool access on grounds of potentially high blood pressure is just illogical.

Conversely, water may actually confer some additional benefits to larger women and birthing people:

Buoyancy

Women’s bodies are generally more buoyant and supported by water than men’s. This support is one of the reasons swimming and aqua aerobics are particularly good forms of exercise while pregnant. But the benefit is likely to be even greater for fatter people, as the increase in fat deposits makes us more buoyant. This in turn eases movement, which may make both maintaining an active labour and facilitating access for monitoring easier.

On land, it is cumbersome and difficult for someone heavily pregnant of any size to quickly move between kneeling, reclining, sitting, leaning, crouching, turning from front to back etc. In water, it is simple and easy to shift to whatever position is most comfortable/convenient, even midway through contractions.

Being in water also promotes positions which are more agreeable for birthing. Lying flat on your back on a bed is one of the worst positions to be in during labour. (OK, standing on your head or halfway up a tree may be worse, but you get my meaning). When you are on your back you are working against gravity; actually trying to push the baby out uphill. It’s only a slight incline, but it’s there. To add to the problem, when lying down, your body weight is also resting on your coccyx (tailbone), forcing it into the pelvic cavity and reducing space for the baby.

In water, even if you were to float on your back, you wouldn’t be putting the same pressure on your tailbone, and you are far more likely to take an upright position, crouching or kneeling, for instance; positions which on land are uncomfortable to maintain, but not in water. This frees up your coccyx to keep out of the way.

Pain relief

It is well documented that warm water can reduce pain felt during labour, and decreases the use of other pain relief. Given the issues with providing epidural anaesthesia, particularly those with obesity, it seems sensible that using water; an effective non-pharmaceutical intervention to help with pain should be encouraged?

As bigger people, we’re often warned of the increased risk of having longer labours. We’re also told we’re more likely to require instrumental deliveries and caesarean sections for ‘failure to progress’. Yet immersion in water has been shown to significantly reduce the length of labour in ‘normal’ (grrrr) sized women. It doesn’t take much of a leap of imagination to consider that water might help to address this problem, at least in some cases?

I think hospitals are bonkers for not encouraging plus-size water birth more!

Need this in a handy, research referenced format to show to your care providers?

If you’re looking for an article which covers all these points, with reference to relevant research publications, to wave in front of a health care professional, I happen to have written that very article for the AIMS journal. You can access it here:

https://www.aims.org.uk/journal/item/waterbirth-high-bmi

What are your options if access is refused?

You know your own body and what you like. If you’re someone for whom relaxation is a couple of hours in a warm bathtub with candles or a book, and a bath is your go to solution for period cramps or other muscular aches and pains, it’s quite probable that water would be an entirely natural component of your birth plan. If the hospital’s policy is a blanket ‘no’ on using the pool, and you are very keen to use water, it’s going to be a struggle. But you do have a few options!

Firstly, my advice would be that if you want a pool, fight for it. Nothing will change for us bigger birthers (BigBirthas!) unless we stand up for ourselves. We should be individually risk assessed for pool use, not pigeonholed and fobbed off.

I thought labouring in water would be really beneficial for me and I was absolutely right. I’m so glad I fought for it and got to experience it with my second baby!

Demand the refusal in writing, on your notes

If you are facing a restriction, or pushback on ANY of your choices, this technique can often help the refuser refocus.

Saying something like “I’d like you to document in my notes that you are refusing [my chosen form of pain relief], purely on the basis of [my size/weight/BMI]” suddenly means they have to take ownership. You don’t want it on your notes that you’re requesting it… You want it on the notes that they are refusing it. It forces the healthcare professional to acknowledge officially the conversation happened. But more than that, what if you then choose an epidural, which goes wrong? Will they have to justify their decision later? Making this potentially throwaway decision on their part suddenly seems a lot less attractive. It also clearly demonstrates the imbalance of power.

This is completely valid! Use of a birth pool is a medical intervention – much like any other. It’s not merely a location, or a background for a selfie – it’s a well-evidenced form of non-pharmaceutical pain relief – so they’d better have a bloody good reason for denying it!!

Reframing their ‘not allowed’ to ‘You are refusing me this reasonable request, and I want that in writing’ can be a helpful tool.

Write to the Supervisor of Midwives/Head of Midwifery

• Request a written explanation (‘It’s our policy’ is not an explanation).
• Follow that up with a request for a meeting so you can challenge the response.
• If you come up against the ‘hoist’ excuse, ask for more information:

Hoists are rated by weight, not BMI. Ask what the weight rating is. After all, a taller woman, while having a lower BMI, could easily weigh more than you. You may be light enough for the hoist’s rating, so argue on that basis.

If you are told there is no hoist on the maternity unit, ask what the provision is for disabled women, as surely to not grant them equality of access is against the law? To say there is no hoist is bunkum; if a disabled person needed a hoist for whatever reason, one would be found. If you are so heavy you need an extra strong bed, one of those would be found… so why can’t a suitable hoist be made available?

Some hospitals don’t use a hoist for pool evacuation in any case, they use an inflatable mat/net. If you’re using an inflatable pool you can deflate the sides to make it easier to get you out (more on that below).

Plus, given that we have a larger percentage of fat, we actually float better than thinner women, so in the event that we did collapse, it would be easier to keep us above water before getting us out than it would be for a skinny minnie!

For every ‘problem’ there is a solution

It’s about whether the hospital staff are willing to work with you to find it.

• If you’re told you can ‘have a bath’ to placate you, be aware that a bath is in no way comparable to a birth pool.

A bath is too narrow and too shallow to allow the complete freedom of movement and support offered by a birth pool. You cannot open your legs wide like a frog while in a bath, or stay immersed while kneeling. You cannot change position quickly and easily in a bath. A bath is unlikely to be deep enough for your back and tummy to be both under the lovely, warm, soothing water simultaneously.

I had to rotate like a rotisserie chicken to try to get the comfort I was seeking in the bath in hospital! Not the soothing experience a pool could and should have been.

Lastly, while baths are shallower, so you’d assume safer, the rooms they are in offer much poorer access. Much more dangerous in case of an emergency! The room I bathed in would barely have accommodated two people as well as myself, not that I considered that risk at the time.

Birth pools are more friendly!

A partner can join you in a birth pool (hospital policy allowing). They certainly can’t do that in a hospital bath – there’s barely enough room for you in there! My husband didn’t join me in our home pool, but our daughter joined me in the early stages!

If the hospital has inflatable pools available for use, a further risk management strategy can come into play – deflating the pool. Our risk management plan for our home birth was to do this rapidly by puncturing the side of the pool with scissors in the (extremely) unlikely event that I ‘crashed’ (pool sited near French doors leading to the garden, so the water wouldn’t have come into contact with any electrics).
This advice is now out of date, and not recommended for safety reasons. The risk of having a sharp implement pointing inwards towards the birthing person as they rapidly and uncontrollably move towards it with the outflow of water, is not the wisest. It is suggested that a better option is to deflate the pool – all designs should still hold most of the water if deflated, but the sides would be more flexible. This may mean a bit of water escapes, but most should stay in the pool. Lots of hospitals have inflatable pools as well as stationary ones, to allow flexibility of room use. You’d need to consider the drainage, but if the hospital has inflatable pools they must surely have already risk assessed the risk of water escaping, so it can be a valid risk management strategy.

Investigate other nearby hospital trusts if needed

If you still come up against a brick wall, you could investigate other potential hospital trusts in the area. It may be that a different hospital that you weren’t considering would be more amenable to your having a water birth, and you can transfer your care there. I transferred care to a different hospital mid-pregnancy in order to access their more home-birth-friendly midwifery team with my second baby.

Ask for a home birth… Even if you don’t want one!

Lastly, you could explore the option of a pool in your own home. Although a hospital can prevent you from using their facilities, it is not in their power to influence what happens under your own roof.

Merely threatening to have a home birth in order to access a pool has been enough for some Trusts to relent and grant access, so this tactic may be worth a shot, even if you’re not serious.

You don’t even have to intend to birth at home, you could just exercise the option to use a pool for as long as possible before transferring in, though this runs the risk of a baby appearing during the transfer.

It is worth remembering that you are legally entitled to a home birth. It is every woman and birthing person’s choice and right, and yours alone. Even if you do not plan for it, you are entitled while in labour to change your mind about attending hospital and decide that you want to stay put. So long as you do not give in to requests by the hospital that you come in, and keep repeating that you want them to send a midwife, they should relent and a midwife will be dispatched to you, as they have a duty of care to you.

Playing The Game Of Home Birth Chicken…

It’s a common tactic for maternity services who are not positive about home birth to ‘not have enough staff on duty’ when someone planning a home birth goes into labour. If that person stays firm that they’re staying at home and that a midwife needs to be sent to her, a midwife is almost always sent, but it can take balls of steel when you’re feeling at your most vulnerable. Have a look on www.homebirth.org.uk for more information.

The only place I can trust that I am in control is in my own home, and barring any medical reason not to birth there again, that’s where any and all of the rest of my kids will be planned to be born.

Birthing Videos on YouTube:

Parker’s Home Water Birth

Eliot’s Home Water Birth

Ava’s Home Water Birth

References

Pain management for women in labour: an overview of systematic reviews – Lewis Jones et al (2012)

Influence of head-out water immersion on plasma renin activity, aldosterone, vasopressin and blood pressure in late pregnancy toxaemia. Kokot et al 1983

Prepregnancy body mass index in non-diabetic women with and without shoulder dystocia Neumann et al (2001)