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Perinatal mortality and morbidity among babies delivered in water: surveillance study and postal survey

BMJ 1999; 319 doi: http://dx.doi.org/10.1136/bmj.319.7208.483 (Published 21 August 1999) Cite this as: BMJ 1999;319:483

Severe blood loss in a neonate due to a ruptured umbilical cord in a bath delivery

In the Netherlands, bath delivery is
increasingly gaining support because of the supposedly advantages such as
reduced maternal pain and stress. About the risks involved, especially for
the neonate, little is known, but a recent study in the British Medical
Journal shed some light on this issue.[1]

We recently encountered a
serious complication of a bath delivery. A healthy 26-year-old mother,
first time pregnant, had an uncomplicated pregnancy. At 39 weeks gestation
she gave birth with delivery in a bath at home, attended by her
midwife. A son of 3 kilograms was born, and immediately after birth, he
was taken out of the water and put on the mothers chest. The umbilical
cord was hanging in the bath water, which was turbid due to blood loss
during delivery. After 3 minutes the child became increasingly pale and
was having trouble breathing. He was taken out of the bath and a total
ruptured umbilical cord was noted with substantial blood loss from the
child. The cord was then clamped and the child had to be resuscitated.

He
was then admitted to our neonatology intensive care unit. On physical exam
1 hour after birth an intensely pale and slightly hypotonic boy with a
moaning respiration was observed, pulse 150 beats/minute, and a mean blood
pressure of 45 mm
Mercury. Laboratory investigations showed a haemoglobin of 7.2 mmol/l with
a haematocrit of 35.7%. Blood gas analysis
showed a pH of 7.18 with a pCO2 of 5.9 kPa. A chest X-ray performed
because of the moaning respiration, showed no
abnormalities. He received red blood cell transfusion, after which his
clinical condition gradually improved. Haemoglobin after blood transfusion
was 9.9 mmol/l. A cranial ultrasound performed the next day showed no
abnormalities. He was
transferred to a neonatology unit of a nearby hospital for additional
care.

In this case a ruptured umbilical cord was not noted because of the
turbid water. Substantial blood loss occurred, and resuscitation and
admission to a hospital was necessary.
Rupture of the umbilical cord usually is a rare but potentially dangerous
event during birth and may result in severe asphyxia and even death. A
ruptured umbilical cord usually is due to a filamentous insertion of the
cord and is easily recognised, due to the large amount of blood loss. It
is tempting to assume that the ruptured umbilical cord in this case would
have been noted earlier if the delivery had not taken place in a bath.

In
a recent study in this Journal the incidence of ruptured umbilical cords
in bath delivery's was found to be as high as 18%. Clearly, impaired
visual control by midwifes, general practitioners or obstetricians
when guiding a bath delivery is a disadvantage in light of the high
incidence of ruptured cords, when compared to other delivery conditions.

We feel that lowering the water level is not sufficient for preventing
this complication, as was suggested in the previous study. It merely
decreases the advantages of giving birth in a bath. We would therefore
like to stress the importance of immediate and thorough investigation of
the newborn and the umbilical cord after bath delivery .

1. Gilbert RE, Tookey PA. Perinatal mortality and morbidity among
babies delivered in water: surveillance study and postal survey. BMJ
1999;319:483-7

Jan H. de Graaf, MD, PhD,

Martijn P. Heringa,* MD, PhD,

Mar J.
Zweens, MD.

Department of Pediatrics, Division of
Neonatology and the Department of Obstetrics and Gynaecology,* University
Hospital Groningen, Hanzeplein 1 9713 GZ Groningen, The Netherlands.

Editorial note
The mother of the baby in this case report has given her signed, informed consent to publication.

Competing interests: No competing interests

25 February 2000
Jan H de Graaf
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