Newborn Died From Infection After Water Birth

Troy Brown, RN

December 11, 2014

A newborn was admitted to a Texas pediatric hospital with sepsis 6 days after undergoing a home water birth and later died, according to a report published in the January 2015 issue of Emerging Infectious Diseases.

Water immersion during labor and birth has become more popular in industrialized countries since the 1980s, Elyse Fritschel, MPH, from the Texas Department of State Health Services in Arlington, and colleagues write.

Legionella species are the agents that cause legionellosis, an illness that can range in severity from a mild illness called Pontiac fever to a potentially deadly pneumonic condition known as Legionnaires' disease. "Legionella species are ubiquitously found in the environment, and their proliferation is supported by warm water and the presence of biofilms," the authors write. Approximately 8000 to 18,000 persons are hospitalized with Legionnaires' disease in the United States each year.

At the time of admission in January 2014, the 6-day-old infant had diarrhea, cyanosis, and respiratory failure. The baby was placed on extracorporeal membrane oxygenation, and ampicillin and gentamicin also were begun. Physicians initially tested for Escherichia coli, group B Streptococcus, or Listeria as the cause of the baby's illness, but suspected legionellosis because of the home water birth and symptoms of fulminant sepsis and respiratory failure.

On day 4 of the infant's hospitalization, Legionella urinary antigen and polymerase chain reaction testing from a tracheal aspirate confirmed Legionella pneumophila serogroup 1. The baby died after 19 days in the hospital, and Legionella infection was confirmed as the cause of death.

Two weeks before the baby's birth, staff from a licensed midwifery center delivered a recreational-grade, jetted, soft-sided, collapsible tub to the mother's home. Staff filled the tub with water from a private borehole well, added commercially available water purifying spa drops to the water, and left the water to circulate in the tub at 37°C until 2 days before the baby's delivery.

The water-purifying drops are enzyme-based and contain no chlorine. In addition, the well water was not filtered or chemically disinfected before use.

Two days before the birth, the tub was drained and refilled, and the well water was again left to circulate at 37°C until the birth. A certified professional midwife delivered the baby, which was born at term by spontaneous vaginal delivery without complications. After the child's birth, the mother moved to her home's bathtub, which had been filled with water from the same well at the time of the birth. The mother held the infant in the bathtub briefly.

The mother had been healthy throughout the pregnancy and had not traveled during the previous 12 months. The Texas Department of State Health Services (TDSHS) recommended environmental testing of the tub in which the baby was delivered and the private well water source. This testing was completed by an Environmental Legionella Isolation Techniques Evaluation laboratory certified by the Centers for Disease Control and Prevention.

The delivery tub had already been drained, disinfected, and placed in storage by the time the testing was recommended. Both the tub and well water tested negative for Legionella.

Areas of Concern

Although this testing was negative, several areas of concern were identified during the investigation, including that the tub used for the birth was a recreational jetted tub with internal tubing that can be hard to disinfect and is not approved for medical use.

The purifying drops added to the water were not approved by the US Food and Drug Administration, and the water was left to circulate at 37°C for "an extended time," the authors note.

In addition, the midwifery center had no written procedures for employees or patients to use before and during the water birth.

The investigation revealed a need for standardized infection control practices for midwives to follow during home water births. The TDSHS wrote recommendations for the midwifery center that delivered the baby and distributed them to the licensing board in Texas, TDSHS regulatory officials, and other professional midwifery organizations in Texas.

The document provided instruction about appropriate cleaning of birthing tubs and recommended that recreational tubs that could not be cleaned and disinfected by these methods not be used.

"The TDSHS strongly encouraged documentation of birthing tub maintenance, including appropriate chemicals and quantities used for disinfection, as well as monitoring of pH and temperature," the authors write.

"These procedural documents were suggested to outline proper timing of tub filling to reduce proliferation of microorganisms, documentation of client awareness of possible risks when deviating from written procedures, and laboratory testing procedures to be followed when birthing tubs are suspected of being contaminated with Legionella or other pathogens."

Other case reports of neonatal legionellosis after water birth have been reported worldwide during the last decade, including a case in the United Kingdom after use of a prefilled, whirlpool-style heated birthing tub similar to the one used in this report.

The authors have disclosed no relevant financial relationships.

Emerg Infect Dis. 2015;21. Full text

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