Irish hospitals suspend waterbirths after aspiration death
According to the
Irish Independent:
Water births have been suspended in maternity hospitals and units following the death of a baby boy who was delivered in a birthing pool.
An inquest heard last week how baby Harry Eccles ... died three days after breathing in water during his birth in a pool at Cavan General Hospital in February 2006.
A spokesperson for Cavan and Drogheda maternity units said the birthing pool service was suspended for births following the incident and was now only available for pain relief.
Cork University Maternity Hospital, which also has a birthing pool, said it would not be using it for births until after the outcome of a national review on water births...
A
newspaper account of the inquest details how the drowning occurred and the findings of the pathologist:
The inquest heard that Harry's death was due to "acute near drowning" after he inhaled water from the birthing pool. A 'near drowning' means that the victim survives temporarily, whether for a matter of hours or days, but ultimately dies. The baby's brain was also starved of oxygen.
Pathologist Dr Peter Kelehan said that it is well known that babies can inhale amniotic fluid while in the womb but that this does not cause any damage to the infant.
He said the changes found in baby Harry's body would not support the theory that he had inhaled amniotic fluids and instead concluded that he had inhaled fresh water during the delivery process.
Instinctively babies should not breathe until they break the surface of the water and meet the air. Instead, they are supposed to continue to be supplied with oxygen through the umbilical cord until they breathe on their own. However, studies have shown that if they don'tget enough oxygen during birth they may gasp for air, running the risk of inhaling water...
"Then the shoulders were born. It was around 60 to 90 seconds after the head before the shoulders were born. I then assisted the baby to the surface of the water," said the midwife.
However, as the baby reached the surface it immediately became clear that something was wrong...
Harry's grandmother, Siobhan Eccles, said that after the baby's head was born, her daughter waited for the next contraction, which never came.
She said when there were no further contractions, Ms Loughran pushed on her daughter's stomach, causing her to "let out a scream".
The midwife denied that she had pushed on Ms Eccles' stomach, but said she had simply put her hands down into the pool to make sure the baby didn't drop to the bottom.
It sounds as though the delivery of the shoulders was slightly delayed, giving the baby plenty of time to inhale a large amount of freshwater. The baby inhaled so much freshwater that when it was absorbed by the lungs, it lowered the concentration of electrolytes in the baby's bloodstream to a level leading to death.
The legal case was further complicated by the fact that the
parents were told that the baby died of a genetic disorder and did not learn about the pathologist's finding of drowning until they attended the inquest.
Barrister for the Eccles family, Sara Antoniotti yesterday told the Coroner that the Eccles family were completely unaware of the pathologist's findings that little Harry died as result of drowning, when many of the people who assisted in his birth were giving evidence, (including midwife, Elisabeth Loughran) at an adjourned inquest on May 8.
As a result the family did not ask the questions that they would have asked had they been aware of the pathologist's findings and wanted an opportunity to ask those questions, the court heard.
"The Eccles family knew nothing about a proposed drowning in a birthing pool - his mother Gina had thought he died as a result of a genetic disorder.
"You can imagine the horror and shock for the family when they discovered this," said Ms Antoniotti.
"This is a most unusual case.
"It's very traumatic for the family and needs to be investigated further.
"It's not only to allay the fears of the family, but the fears of the general public," she said.
It seems that the hospital was aware of its culpability and hoped to hide it by telling the parents that the baby died from an unpreventable genetic disorder.
Labels: neonatal mortality, water birth
The diving reflex: a little knowledge is a dangerous thing
There is an old saying that "a little knowledge is a dangerous thing" and that is certainly the case in homebirth midwifery. A classic example is the claim that waterbirth is safe because of the "diving reflex". There is, indeed, a diving reflex, but it does not mean what homebirth midwives think it means. Because homebirth midwives do not understand the basic physiology of the diving reflex, they do not understand that it cannot and will not prevent a baby from breathing when born in water.
The scientific paper
Respiratory responses to cold water immersion: neural pathways, interactions, and clinical consequences awake and asleep contains an explanation of the diving reflex. The explanation is highly technical, but the basic facts are these:
1. The diving reflex exists to prevent drowning. Its primary purpose is to minimize oxygen consumption in pathological situations. It is elicited by the stress of attempting to avoid death, not as a typical response to normal phenomena.
2. Breath holding is only one aspect of the diving reflex. The others are bradycardia and peripheral vasoconstriction; neither bradycardia (slow heart rate) or peripheral vasoconstriction (diminished blood flow to non-essential organs and tissues) are normal events. Bradycardia can be so profound as to lead to cardiac arrhythmias or cardiac arrest.
3. The diving reflex is elicited by COLD water, not by room temperature or warm water.
These facts raise several important questions about waterbirth:
The diving reflex exists to prevent drowning. Clearly babies are not supposed to be in a situation where they might drown. Why would you deliberately expose a baby to drowning and rely on a reflex to save itself from pathological exposure to water? The diving reflex exists because it is UNNATURAL and HARMFUL for the baby to be submersed.
Why would you deliberately expose a baby to the dangers of bradycardia and peripheral vasoconstriction (both being efforts of the body to decrease oxygen consumption to survive pathological oxygen deprivation)?
Why would you rely on a reflex is not even elicited in the presence of warm water?
The authors specifically address the physiologic response to waterbirth. Discussing the claims of waterbirth proponents, they write:
For some time it has been thought that the vagally mediated triad of responses to trigeminal nerve stimulation (apnea, bradycardia, and selective vasoconstriction) that constitute the oxygen conserving "diving response" provides protection against drowning for babies during underwater birth by conserving oxygen. However, it is known that the response in neonatal animals is markedly diminished in the presence of hypoxemia, as can occur with a difficult delivery, and recently underwater birth has been linked to neonatal distress and mortality as part of a near-drowning scenario with radiological evidence consistent with lung aspiration of birthing pool water. Thus it appears that the apnea associated with the diving response is insufficient in newborn babies to ensure that water is not inhaled during underwater delivery.
In other words, the diving reflex does not prevent neonatal drowning in a birth pool of warm water. Those who understand the diving reflex would not expect it to prevent waterbirth drowning.
The key point is this: anyone with a comprehensive knowledge of the diving reflex would never claim that it could prevent drowning at waterbirth.
There is a diving reflex, but it does not work the way midwives claim, its effects are not limited to breathholding, and it is elicited by cold water, not warm water.Waterbirth is the epitome of an unnatural stunt claiming to be "natural" simply because it ignores scientific evidence.
Labels: water birth
Baby dies of freshwater drowning at waterbirth
According to
Birth pool baby 'drowned' in the Independent of Ireland:
A baby died of "acute near drowning" three days after a natural water birth, an inquest heard yesterday.
Gina Eccles (24) gave birth to baby Harry in a birthing pool at Cavan General Hospital on February 26, 2006, helped by a midwife.
After birth, the baby boy was blue in colour, unresponsive to tactile stimulation and made no efforts to breath on his own, Dublin City Coroner's Court heard yesterday.
He was immediately ventilated and was transferred to the National Maternity Hospital, Holles Street, Dublin, later that day where he died on March 1.
Pathologist Dr Peter Kelehan told the court yesterday that baby Harry had died from an acute "near drowning" event after inhaling fresh water into his lungs.
He said the baby had exhibited hyponatremia or low sodium levels which is "a characteristic of freshwater drowning."
He added there was no evidence of disease which might have caused the baby's demise.
"I was not able to find any lesion which existed before this catastrophic event at the time of the baby's birth," he said.
Neuropathologist at Beaumont Hospital, Dr Michael Farrell, was also of the opinion that the event occurred at birth, Dr Kelehan told the court...
This tragic outcome is consistent with a study of water birth published in the BMJ in 1999,
Perinatal mortality and morbidity among babies delivered in water: surveillance study and postal survey which found that out of 4,030 deliveries in water, 35 babies suffered serious problems and 3 subsequently died. It is unclear if any of the deaths can be attributed to delivery in water. However, of the 32 survivors who were admitted to the NICU, 13 had significant respiratory problems including pneumonia, meconium aspiration, water aspiration, and drowning. Other complications attributable to water birth include 5 babies who had significant hemorrhage due to snapped umbilical cord. In all, 18 babies had serious complications directly attributable to waterbirth. The risk of serious complications necessitating prolonged NICU admissions was 4.5/1000.
The American Academy of Pediatrics Committee on the Fetus and Newborn released a comprehensive report in 2005 that waterbirth is not safe for babies. The report,
Underwater Births, begins:
Throughout human existence, women have typically given birth to their offspring on land. Over the last 25 years, however, underwater birth has become more popular in certain parts of the world despite a paucity of data demonstrating that it is either beneficial or safe.1–22 Underwater birth occurs either intentionally or accidentally after water immersion for labor, a procedure promoted primarily as a means of decreasing maternal discomfort. A review of the available literature indicates that the risks of underwater birth to the newborn seem to outweigh the benefits, and caution is urged before widespread implementation.
After reviewing the existing scientific literature, the committee concludes:
The safety and efficacy of underwater birth for the newborn has not been established. There is no convincing evidence of benefit to the neonate but some concern for serious harm. Therefore, underwater birth should be considered an experimental procedure that should not be performed except within the context of an appropriately designed RCT after informed parental consent.
Labels: water birth
Waterbirth study shows significant perinatal mortality and morbidity
Perinatal mortality and morbidity among babies delivered in water: surveillance study and postal survey was published in the BMJ in 1999. It is an attempt to study the outcomes of 4,030 deliveries in England and Wales. The study suffers from the serious flaw that it does not have a control group with similar characteristics. The authors compare the mortality and morbidity to women delivering a baby from the vertex presentation. This could contain (and likely does contain) many women who are much higher risk than the women in the waterbirth group.
Nonetheless, it is instructive to look at the results. Out of 4,030 babies delivered in water, 34 were admitted to intensive care nurseries, of which 3 subsequently died. According to the study:
All three postpartum deaths were associated with abnormal pathological findings: one baby died aged 3 days with neonatal herpes infection; one died aged 30 minutes with an intracranial haemorrhage after precipitate delivery; and the third, who died aged 8 hours, was found to have hypoplastic lungs at postmortem examination.
Of the 32 survivors, 13 required respiratory support (ventilation or continuous positive airways pressure-6 or head-box oxygen-7). Fifteen of the survivors had lower respiratory tract problems, variously labelled as pneumonia, transient tachypnoea of the newborn, or "wet lung"-9; suspected aspiration-3; meconium aspiration-1; water aspiration-1; and "freshwater drowning"-1.
Hypoxic ischaemic encephalopathy grade 2 or 3 or perinatal asphyxia was reported in 5 surviving children, including the baby in whom freshwater drowning was diagnosed...
In the 32 survivors, 15 had other diagnoses or reasons for admission. Five babies had a snapped umbilical cord (of whom 1 required a transfusion, 1 developed hypoxic ischaemic encephalopathy grade 2, and 1 had a chromosomal abnormality). One further baby had a chromosomal abnormality; one developed hypoxic ischaemic encephalopathy grade 3 and had transposition of the great arteries; three had stridor; and one had shoulder dystocia. No clear reason or diagnosis was given for the remaining 4 babies.
In summary, out of 4,030 deliveries in water, 35 babies suffered serious problems and 3 subsequently died. It is unclear if any of the deaths can be attributed to delivery in water. However, of the 32 survivors who were admitted to the NICU, 13 had significant respiratory problems including pneumonia, meconium aspiration, water aspiration, and drowning. Other complications attributable to water birth include 5 babies who had significant hemorrhage due to snapped umbilical cord. In all, 18 babies had serious complications directly attributable to waterbirth. The risk of serious complications necessitating prolonged NICU admissions was 4.5/1000.
The authors concluded that these morbidity and mortality are similar to rates in other studies, but they fail to control for risk, so highly likely that the waterbirth group was much lower risk than the comparison group.
In my judgment, this is a pretty serious indictment of waterbirth.
Labels: neonatal mortality, water birth
American Academy of Pediatrics says waterbirth is not safe
One of the more unusual practices claimed to be part of "natural" childbirth is waterbirth. Waterbirth is not natural for any primates, does not have historical precedent, and was only invented and used in the last 25-50 years.
The American Academy of Pediatrics Committee on the Fetus and Newborn released a comprehensive report last year that waterbirth is not safe for babies. The report,
Underwater Births, begins:
Throughout human existence, women have typically given birth to their offspring on land. Over the last 25 years, however, underwater birth has become more popular in certain parts of the world despite a paucity of data demonstrating that it is either beneficial or safe.1–22 Underwater birth occurs either intentionally or accidentally after water immersion for labor, a procedure promoted primarily as a means of decreasing maternal discomfort. A review of the available literature indicates that the risks of underwater birth to the newborn seem to outweigh the benefits, and caution is urged before widespread implementation.
After reviewing the existing scientific literature, the committee concludes:
The safety and efficacy of underwater birth for the newborn has not been established. There is no convincing evidence of benefit to the neonate but some concern for serious harm. Therefore, underwater birth should be considered an experimental procedure that should not be performed except within the context of an appropriately designed RCT after informed parental consent.
Labels: water birth
Water birth
I've always wondered about the place of water birth in the homebirth movement. One of the cornerstones of the homebirth movement seems to be the feeling that natural is "best" and that birth should occur the way nature intended. So where does water birth fit in? It is emphatically not natural! Human babies are not supposed to be born underwater. No primates give birth underwater. How can this completely artificial (and apparently dangerous) way of giving birth be reconciled with the homebirth movement?
Labels: water birth
