I’m a big fan of water birth for plus-size women. The fact that I was denied access to a birth pool in hospital on the basis of my size is one of the main reason this website exists!
What is waterbirth?
‘Waterbirth’ can be used to mean both labouring and delivery of the baby while in water.
Although it tends to be seen as a ‘new’ idea with the arrival of birth pools designed specifically for the purpose, immersion in water has been used for centuries and across all continents to help women manage their labours.
It is easy to see how/why; many women experimenting while in labour find that lying in a warm bath helps to soothe their contractions. A birth pool is merely a larger, deeper version of this which facilitates full immersion even when seated, as domestic baths are not deep enough or wide enough to be comfortable to a labouring woman for long.
Birthing pools are similar in size to a hot tub, but with no jets. Often they have steps or seats built into them, and handrails to grab onto, and this applies whether they are a permanent, plumbed-in fixture of a room, or an inflatable or otherwise movable structure.
Most UK maternity hospitals and midwife led delivery units now have access to a birthing pool. For many, this is a permanent fixture in a delivery room, and use depends on it not being occupied by another labouring woman.
Alternatively, or sometimes in addition to the above, some maternity settings also have movable, multi-use birthing pools which can be moved to different rooms or even loaned out for use in the community.
Finally, there is always the option to have a birthing pool at home. There are a number of 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! If you don’t want to or can’t afford to buy your own pool, there are also companies, charities, and health services who hire them out.
Research has shown that using water during labour reduces the amount of pain reported by women, resulting in a reduction in the use of other forms of pain relief; shorter labour durations; and increased satisfaction for the mother.
I can certainly confirm this is true in my case – I was hugely surprised by the intensity of the contractions as soon as I needed to leave the comfort of the pool for examinations or to use the loo. Contractions that had been perfectly bearable in water were suddenly much harder to manage on dry land! 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.
***addendum*** in 2014, a baby born in a pool that had been filled some time in advance of the labour and the temperature maintained by use of a heater and pump contracted Legionnaire’s disease, a serious lung infection. The legionella bacteria was traced back to the birth pool. Public Health England now recommend that pools are not filled in advance of labour. For more information, read the Water Birthing Pools and Legionnaires Risk page. ***
Water can be used at any stage in labour, though its use is more common in the early stages. Many women who choose to labour in water are comfortable giving birth in water, others prefer to do so on dry land.
It is not uncommon for a woman in labour to change her mind about where she wants to birth her baby, despite having had strong opinions about it beforehand, so it is often not possible to know your real preference until the time comes.
There are reasons you may want to leave the pool; to visit the toilet, so your midwife can examine you to check progress, to eat, etc., but with modern, waterproof equipment being developed, there are fewer reasons to leave the pool for routine monitoring, as a waterproof doppler can be used to monitor the baby’s heart rate etc.
There is no evidence to suggest that labouring or birthing in water is unsafe for bigger women.
That’s because there is no evidence on obese women using birth pools full stop. All evidence refers only to ‘low-risk’ pregnancies. So, we are no more able to say that plus-size water birth is unsafe than we are able to say that it is more safe. There is no evidence either way.
However, reasons cited by some hospitals for barring women on the grounds of BMI alone are:
Health and Safety (surprise!): If you collapsed, it would apparently be an issue for staff trying to get you out; but there are plenty of options to counter this argument – please read further below!
Shoulder dystocia: It is often argued that bigger women are more prone to babies with shoulder dystocia (where the head is born, but the shoulders get stuck). There is some argument that when gestational diabetes and macrosomic (big) babies are accounted for, bigger women are no more likely to experience shoulder dystocia than ‘normal’ sized women, but because the number of births with shoulder dystocia are so small (less than half a percent), studies would have to have massive sample sizes to have enough cases to begin to factor out extra complications and get an accurate picture.
Given that the primary course of action in cases of shoulder dystocia is for the mum to change position, water may even help by giving the labouring woman greater freedom of movement to change her position, widen her pelvis, and enable the shoulders to be born.
High blood pressure: There can be a concern that obese women, who are more likely to have high blood pressure, could collapse. But not all women with a high BMI have high blood pressure, so it is illogical to ban plus-size water birth when blood pressure can so easily be checked and monitored and specifically excluded if need be. 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. Ironically, immersion in water is also associated with lowering blood pressure as it has a calming effect!
Conversely, water may actually confer some additional benefits to obese women:
All women are more buoyant and supported by water, it’s one of the reasons swimming and aqua aerobics are particularly good forms of exercise while pregnant. But the benefit is likely to be greater for obese women, as fatter bodies are naturally more buoyant.
The buoyancy and support provided by water eases movement, which may make both maintaining an active labour and facilitating access for monitoring easier. On land, it is cumbersome and difficult for a heavily pregnant woman 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.
It is well documented that warm water reduces pain felt by labouring women, and decreases the use of other pain relief. Given the issues with providing epidural anaesthesia to obese women, it seems sensible that using water; an effective non-pharmaceutical intervention to help with pain should be an attractive alternative?
Obese women are at increased risk of having longer labours, and of moving on to instrumental delivery and caesarean sections for ‘failure to progress’. Yet immersion in water has been shown to significantly reduce the length of labour in ‘normal’ 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 obese women?
I think hospitals are bonkers for not encouraging plus-size water birth more!
If you have a BMI of over 35, you may find it difficult to find a hospital setting which will allow you to use their birthing pool. Some maternity settings have a sensible case by case, individualised risk assessment approach to larger women using pools. 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 birth pool, and you are booked in to use the delivery suite, DO NOT ASSUME you will be allowed to use the pool!
Even if you mention that you want to use the pool at your antenatal appointments and no-one says you can’t, DO NOT ASSUME you will be allowed to use the pool!
Even if you had a water birth with the particular Hospital Trust previously, DO NOT ASSUME you will be allowed to use the pool!
Submit a freedom of information request as early in your pregnancy as you can and/or request a copy of the policies from your midwife. Some individual hospital policies can be found here, but they do change.
Ironically, hospitals which have a ‘no pools for women with a BMI 35+’ usually justify this by saying that in the event of an emergency, it would be a health and safety issue for staff trying to get you out, yet they don’t prevent you from using their baths while in labour, which are usually in more cramped surroundings, and don’t offer the usual 360° access of a birth pool?!
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 seems an entirely natural component of your birth plan. If the hospital’s policy is a blanket ‘no’ on obese women using the pool, and you are very keen to use water, you have a few options.
Firstly, my advice would be that if you want a pool, fight for it. Nothing will change for us bigger mums 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, and I’m so glad I fought for it and got to experience it with my second baby!
- You can write to the Supervisor of Midwives/Head of Midwifery. Request a written explanation. (‘It’s our policy’ is not an explanation), and then 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, and 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 shut you up, challenge that.
A bath is in no way comparable to a birth pool.
I had two baths in hospital while in labour with my first baby (while waiting for the pool that no-one was brave enough to tell me I wasn’t going to be allowed to use).
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. You cannot stay immersed while kneeling in a bath. You cannot change position quickly and easily in a bath. A bath is not 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! Not the wholly soothing experience it could have been.
You are more bouyant in water (if you’re given the room to be) and therefore moving position and keeping mobile is much easier. I was even able to move during contractions if I chose to while in the water – something that is nigh on impossible on land, and I could choose to move in almost any direction; sit, stretch out, kneel, float on my back, legs wide, legs together, whatever I fancied at the time, which was very liberating, all while being supported and soothed by the water.
Lastly, while baths are shallower, so you’d assume safer, the rooms they are in offer much poorer access than ones with pools (which usually are designed for 360 degree access to the birth pool) – much more dangerous in the 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.
Finally, 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, namely the risk of having a sharp implement pointing inwards towards the mother while she is rapidly and uncontrollably moving towards it with the outflow of water. 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.
- 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.
- 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 about it. 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.
It is worth remembering that you are legally entitled to a home birth. It is every woman’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.
(It’s a common tactic for maternity services who are not positive about home birth to ‘not have enough staff on duty’ when a woman planning a home birth goes into labour, but if the woman stays firm that she is staying at home and that a midwife needs to be sent to her, a midwife is almost always sent. Have a look on www.homebirth.org.uk for more information.)
If I ever get pregnant again, I’m going to be far more of a ‘problem’ about this than I was last time. I’m going to make waves, (ha ha!) to try and change policies for the better for everyone, locally to me, at least, even though I’d ultimately plan a home birth anyway.
My trouble is, even if I did get them to concede to let me use the pool in the hospital/birth centre, I wouldn’t trust them to hold true to their word on the day I actually go into labour, because that’s the mistake I made with my first baby.
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:
Immersion in Water During Labour and Birth (257.3 KiB)
Immersion in water in labour and birth (Review) (741.1 KiB)