Giving Birth
Water Birth
A guide to water birth: how it differs from labouring in water, individual suitability, current NICE and ACOG guidance, possible maternal and neonatal outcomes, umbilical cord avulsion, monitoring, infection control and facility requirements.
Important medical note
Water birth is a provider-dependent option requiring individual assessment and appropriate maternity-facility protocols. International recommendations are not uniform: NICE has recommended since 2025 that water birth can be considered with informed discussion of benefits, risks and uncertainty, while ACOG continues to recommend that birth itself occur on land. The decision should be discussed with the maternity team responsible for the pregnancy and birth.
What is a water birth?
Water birth means remaining in a birth pool during the final stage of labour so that the baby itself is born while the mother is immersed.
This is different from labouring in water, where a woman may use the pool for comfort and pain relief but leave before birth.
The distinction matters because evidence and protocols for underwater birth are not identical to those for first-stage water immersion.
Professional guidance
Not internationally uniform
NICE has recommended since 2025 that water birth can be considered, while ACOG continues to recommend that birth itself occur on land.
Evidence
Potential benefits and risks
NICE reports possible benefits for some outcomes and an increased risk of cord avulsion, while evidence about fetal or neonatal death remains inconclusive.
Availability
Provider dependent
Water birth requires candidate-selection criteria, monitoring, infection-control protocols, trained staff and a clear emergency-transfer plan.
Water birth is different from labouring in water
Using a birth pool during labour does not automatically mean the baby will be born in the water.
A woman may labour in the pool and leave before birth.
Water birth specifically means remaining immersed while the baby is born.
These should therefore be represented as separate maternity capabilities.
Why professional guidance differs on water birth
Evidence on underwater birth has developed, but professional bodies do not interpret the evidence identically.
NICE
NICE updated its recommendation in 2025 and now says to consider water birth.
The woman should be informed about potential benefits, potential risks and outcomes for which evidence remains inconclusive.
ACOG
ACOG's Committee Opinion, reaffirmed in April 2025, remains more cautious.
ACOG considers evidence on second-stage immersion and underwater delivery insufficient to determine the relative benefits and risks, and recommends that birth itself occur on land.
This disagreement should be visible during informed decision-making rather than presented as if there were one universal international position.
Who can discuss water birth?
Suitability cannot be determined by an online page or automated selection.
Evidence underpinning the NICE recommendation mainly relates to low-risk, term, singleton pregnancies.
Exact operational criteria still vary between maternity facilities.
Maternal health, fetal wellbeing, gestational age, pregnancy history and labour progress need to be reassessed during maternity care.
Facility capability does not equal individual eligibility.
Potential maternal benefits discussed by NICE
The evidence reviewed by NICE comes from large non-randomised studies.
The findings therefore describe associations and cannot prove that water birth itself causes each difference.
Severe perineal trauma
Water birth may be associated with a lower risk of third- or fourth-degree perineal trauma in multiparous women.
The same difference was not demonstrated clearly in nulliparous women.
Postpartum haemorrhage
The evidence also suggests a lower likelihood of postpartum haemorrhage among those giving birth in water.
NICE cautions that this does not mean a woman with an already increased baseline haemorrhage risk becomes low risk by choosing water birth.
Neonatal-unit admission
NICE also reports a lower rate of neonatal-unit admission in the evidence reviewed.
This result should be interpreted in the context of observational evidence and candidate selection.
Umbilical cord avulsion is a water-birth-specific concern
NICE found an increased risk of the umbilical cord snapping before clamping among babies born in water.
The absolute risk remains small, but some studies showed a higher rate than birth out of water.
Staff therefore need appropriate experience and protocols for handling the baby and cord after underwater birth.
Water birth should not be described as having no water-specific risks.
What evidence remains uncertain?
Fetal or neonatal death
NICE states that evidence on the risk of the baby dying during or after birth is inconclusive.
Current evidence cannot establish whether water birth increases, reduces or does not change this outcome.
Rare serious complications
Rare adverse outcomes are difficult to measure reliably even in large studies.
ACOG highlights reports of uncommon but serious neonatal complications, including infection, water aspiration and umbilical cord injury.
This uncertainty is one reason ACOG remains more cautious than NICE about underwater birth.
Monitoring, water temperature and infection control
Water birth requires more than access to a pool.
A maternity service needs protocols for candidate selection, maternal and fetal monitoring, water temperature, pool cleaning, infection control and emergency response.
Water temperature
NICE recommends hourly monitoring of maternal and water temperature while labouring in water.
Water temperature should not exceed 37.5°C.
Infection control
Birth pools should be cleaned according to an agreed infection-control protocol and manufacturer instructions where applicable.
These operational safeguards remain important when the baby itself is intended to be born in water.
When the plan may need to change to birth out of water
A preferred water birth should remain a flexible birth plan.
Leaving the pool may be recommended if maternal or fetal concerns develop, or if monitoring, assessment, analgesia or treatment cannot be provided appropriately while immersed.
The plan may also change if labour does not progress or another mode of birth becomes clinically appropriate.
Leaving the pool should not be described as a failed birth plan.
Care immediately after an underwater birth
The baby still requires normal newborn assessment after birth.
When mother and baby are well, early contact can continue according to the facility protocol.
If neonatal assessment or support is required, the facility should be able to move the baby to appropriate care without unnecessary delay.
The third stage
Placental management and postpartum-haemorrhage planning should follow the individual third-stage plan and facility protocol.
It should not be assumed that every post-birth step will occur inside the pool.
Planning a water birth in Saudi Arabia
Water birth capability should not be assumed at every maternity facility.
The actual facility and its protocol need to be verified before relying on water birth in a birth plan.
Questions to ask the facility
- Does the facility offer underwater birth or labour in water only?
- What eligibility criteria are used?
- Who attends water births and what experience does the team have?
- How are maternal and fetal wellbeing monitored?
- What are the water-temperature, cleaning and infection-control protocols?
- What circumstances require leaving the pool?
- How does the team respond to umbilical cord avulsion?
- How quickly can another intervention or cesarean be provided if needed?
- What neonatal support is available?
Provider capability does not guarantee eligibility or outcome
LahaLak represents water birth as a provider-dependent maternity option requiring clinical assessment.
A listed capability means the maternity facility can potentially support the pathway.
It does not guarantee that every woman will be eligible, or that the baby will ultimately be born in water if circumstances change.
Frequently asked questions about water birth
Answers about water birth versus labouring in water, NICE and ACOG guidance, possible benefits, cord avulsion, uncertainty, eligibility and facility availability.
Is water birth the same as labouring in water?
No. Labouring in water can end with birth outside the pool, while water birth means the baby itself is born underwater.The two should be checked as separate maternity-facility capabilities because some facilities support labour immersion without underwater birth.
Does NICE recommend water birth?
Since its 2025 update, NICE says water birth can be considered after discussion of benefits, risks and uncertainty.The discussion includes possible reductions in some outcomes, an increased risk of cord avulsion and inconclusive evidence about fetal or neonatal death.
Does ACOG recommend water birth?
ACOG continues to recommend that birth itself occur on land.Its Committee Opinion considers evidence for second-stage immersion and underwater delivery insufficient to determine relative benefits and risks, despite supporting first-stage immersion for selected pregnancies.
Does water birth reduce severe perineal tears?
NICE reports a possible lower risk of severe tears in multiparous women.The same difference was not clearly shown in nulliparous women, and the evidence is observational rather than proof that water itself causes the difference.
What is the umbilical cord concern with water birth?
NICE found an increased risk of the cord snapping before it is clamped.The absolute risk remains small, but this is a water-birth-specific risk that the attending team needs to be prepared to manage.
Can anyone guarantee that water birth is completely safe for the baby?
No such guarantee can be made.NICE considers evidence about fetal or neonatal death inconclusive, while ACOG also highlights uncertainty around rare but serious neonatal complications.
Could I need to leave the pool before the baby is born?
Yes. Water birth should remain a flexible plan.Leaving may become necessary if maternal or fetal concerns develop or if monitoring, treatment or another mode of birth becomes more appropriate.
Does every maternity hospital offer water birth?
No. Availability should be verified with the individual facility.Water birth requires suitable equipment, trained staff, candidate-selection criteria, monitoring, infection control and an emergency-response pathway.
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