Case report of neonatal near drowning associated with underwater birth

Introduction

Water birth is thought to be an advantageous method of delivery for the mother for the following reasons: reduced requirement for analgesia in labour and shorter labour with fewer interventions, as compared with other positions and modes of delivery [1], [2], [3]. Furthermore, it is suggested that water immersion increases maternal satisfaction and sense of control, in addition to enhancing maternal emotional wellbeing postnatally [4], [5].

However, there are some concerns about water birth related to the foetus/neonate. The key concerns include: thermoregulation during labour, infection and onset of respiration at birth [6], [7], [8], [9], [10], [11]. There are several reports of death attributable to drowning resulting from poorly managed water births [10]. It has been suggested that water aspiration makes ventilation very difficult, despite having experienced staff present [11].

We present a case report of a baby born via planned underwater birth. The report illustrates water aspiration, haemorrhagic pulmonary oedema, coagulopathy and hyponatraemia, hence the possibly of increased risk of perinatal morbidity associated with water birth.

Ethics Approval was granted by the ACT Health Human Research Ethics Committee (No ETHLR.10.378).

Case report

A female infant was born via planned underwater birth at 41 weeks’ gestation. There were no maternal risk factors for infection. The baby was managed by brief mask ventilation and continuous positive airway pressure (CPAP) ventilation at birth. The baby was admitted to the Neonatal Intensive Care Unit because of respiratory distress (RDS) soon after. Following further deterioration of her respiratory status, she was intubated and ventilated at 3 h of life. Chest X-ray showed diffuse widespread bilateral fine interstitial reticular pattern (Figure 1). A single dose of surfactant was given, resulting in substantial clinical improvement. On day 2 of its life, the baby developed frank blood-stained endotracheal aspirate consistent with haemorrhagic pulmonary oedema. Coagulation studies were deranged [prothrombin time (PT) 19 (normal: 9–15) s, partial thromboplastin time (PTT) 68 (normal: 28–41) s and international normalized ratio (INR) 1.7 (normal: 0.8–1.2)]. This was treated with fresh frozen plasma transfusion, sedation and increased positive end-expiratory pressure (PEEP). Ventilation was continued for 2 days. At 5 days, a course of IV ampicillin and gentamicin was administered but no organisms grew on blood culture.

Figure 1:

Chest X-ray at 2 h of age showing diffuse, widespread bilateral interstitium, characterised by a fine reticular pattern.

Hyponatraemia was detected on day 1 and was corrected slowly with IV sodium infusion. The lowest plasma sodium was 117 mEq/L; serum and urine osmolality were normal, and urine sodium was <20 mmol/L.

Our working diagnosis was water aspiration associated with underwater birth. This baby was discharged home on day 6 and was well on follow-up at 6 weeks of age.

Discussion

The neonate described here was born underwater and required respiratory support and admission to the neonatal intensive care unit (NICU). Chest X-ray confirmed likely water aspiration with secondary surfactant deficiency and pulmonary haemorrhage. We suspect that as a result of water aspiration, the baby became coagulopathic and hyponatraemic. These complications required admission of the baby to the NICU and resulted in a prolonged stay in hospital for both mother and baby. Consequently, the neonate was separated from the mother.

As there were no organisms grown on blood culture to suggest that infection was a contributing factor, nor were there any risk factors for sepsis before delivery or meconium, we concluded that the likely diagnosis was water aspiration.

In a report on four infants with water aspiration, Nguyen et al. provided additional evidence that water birth causes adverse outcomes [8]. The authors’ argument for causality rests on the demonstration of radiograph appearances of gross pulmonary oedema and, in one infant, hyponatraemia [8].

It seems there is increasing concern that water birth may lead to increased perinatal morbidity, due to a number of case reports [6], [7], [8], [9], [10], [11] and no clear, high-quality evidence to the contrary [3]. Any woman contemplating water birth should be well aware of the possible outcomes for the neonate including water aspiration, infection, pulmonary oedema, pulmonary haemorrhage, coagulopathy, hyponatraemia and prolonged hospital stay.