Umbilical cord nonseverance (UCNS) is the practice of leaving the umbilical cord attached to the placenta after delivery. Limited case reports exist revealing adverse outcomes of UCNS. We report a case of neonatal omphalitis associated with Escherichia coli bacteremia and urinary tract infection after UCNS.
Umbilical cord nonseverance (UCNS), often referred to as lotus birth, is the practice of leaving the umbilical cord uncut so that both the cord and placenta remain connected to the infant after birth.1 The cord is allowed to detach naturally, usually ∼10 days after birth.2 The placenta is typically stored in a bag or other fabric,2–4 and aromatic salts and herbs may be applied2,3,5 (Fig 1). Although numerous reports regarding the practice of UCNS itself have been described, limited medical information regarding UCNS has been published. In a sample of mothers electing for home birth, including some desiring UCNS, mothers described the placenta as belonging to the infant and not as a medical byproduct. Women shared that cleanliness and medical benefits were secondary concerns, whereas spirituality of the practice was highlighted.4 Holistic beliefs toward UCNS certainly describe a benefit to mothers and infants. However, it is also important to consider whether there are any health outcomes, positive or negative, associated with UCNS to best treat patients who request this method of managing the placenta and umbilical cord.
Example of UCNS with placental storage and treatment after delivery (courtesy of Monroe et al9 ).
Example of UCNS with placental storage and treatment after delivery (courtesy of Monroe et al9 ).
After delivery, the blood in the placenta is no longer circulating, rendering the placental tissue nonviable. The placenta may then be at risk for becoming infected, which subsequently could theoretically spread to the infant in cases of UCNS.1 Besides case reports, no evidence-based research devoted to clinical outcomes has been published for UCNS. Regarding the potential incidence of infection associated with UCNS, omphalitis may provide the most comparable data, which is estimated to occur at an incidence of 1 per 1000 live births in high-resource countries.6 However, the true incidence of infection with UCNS remains unknown.
Limited case reports exist revealing adverse outcomes of UCNS. The first was not described until 2017, when a case report revealed a possible link to idiopathic neonatal hepatitis.7 Subsequent cases associated with UCNS were reported for isolated neonatal Staphylococcus lugdunensis endocarditis, neonatal hyperbilirubinemia, and neonatal omphalitis without bacteremia.8 At our institution, a limited 6-case series of UCNS was published in 2019, with no reported adverse outcomes.9 However, shortly after publication, the first adverse event–associated case related to UCNS occurred. We report a case of omphalitis and Escherichia coli bacteremia and urinary tract infection associated with UCNS.
Case Description
A 3-day-old boy presented for a well visit. Birth history was significant for spontaneous hospital vaginal delivery at 39 weeks’ gestation. Group B Streptococcus screening was negative, and prenatal laboratory tests, including rubella, hepatitis, sexually transmitted infection panels, and HIV, were unremarkable. There was no history of intrapartum fever. His delivery was unremarkable, with Apgar scores of 9 at both 1 and 5 minutes of life. Birth weight was 3785 g (appropriate for gestational age). Parents requested the umbilical cord and placenta remained intact. The care of the attached umbilical cord followed institutional UCNS policy, including daily examination, maintenance of cleanliness, and placement of the placenta in close proximity to the infant. The remainder of his newborn stay was uneventful. He was discharged at 36 hours postdelivery and in good condition. At his hospital follow-up visit, parents requested to have his umbilical cord cut. Because of his clinical examination findings, he was referred to the emergency department.
On physical examination, the umbilical cord was intact at the base of the umbilicus and connected to the placenta. Erythema was present at the umbilicus, with extension circumferentially (Fig 2). Trace yellow exudate was noted. There was no crepitus or induration. The abdomen was soft, nontender, and nondistended. No other rashes, jaundice, or petechiae were appreciated. The infant was uncircumcised. The remainder of the examination was normal for a term newborn boy, and vital signs remained age appropriate. Diagnostic evaluation was performed. Complete blood count and comprehensive metabolic panels were within normal limits. Procalcitonin was elevated to 0.43 ng/mL (reference range: 0–0.25 ng/mL). He was started on empirical antibiotics with intravenous cefotaxime and intravenous clindamycin. Peripheral blood culture grew Gram-negative rods at 17 hours, speciating to E coli (resistant to ampicillin, ampicillin-sulbactam, and cefazolin). Catheterized urinalysis was significant for trace blood and bacteria visualized on microscopy but notably a lack of pyuria. Urine culture grew 1000 to 10 000 colony-forming units of E coli (ampicillin resistant). Renal ultrasound was normal. A lumbar puncture was discussed with parents who, after counseling on the risks and benefits of the procedure, declined.
A diagnosis of omphalitis was made on the basis of clinical presentation of erythema and purulent discharge from his umbilicus that resulted in E coli bacteremia, E coli bacteriuria, and presumed meningitis given his age and Gram-negative–rod bacteremia. His blood cultures revealed no growth for 48 hours on 2 subsequent cultures. Parents continued to decline lumbar puncture, therefore necessitating a 21-day course of cefotaxime for presumed meningitis. He received a 10-day course of clindamycin for treatment of omphalitis. He received the total duration of his antibiotic course inpatient without complications and was discharged from the hospital in stable condition to the care of his parents.
Discussion
UCNS is an uncommon birth practice, and pediatricians may be unfamiliar with the management of this situation. Pediatricians may encounter difficulties providing best-practice recommendations and counseling on the risks when UCNS is requested by parents because the true risk-and-benefit profile is unknown. Although the overall complication rate associated with UCNS is unknown, our case reveals that serious bacterial infections may result. We previously reported a 6-case series including UCNS over a period of 33 months in an institution with >4500 deliveries per year.9 Although there were no reported adverse outcomes in this primary analysis, we subsequently encountered this case associated with serious bacterial infection. In previous case reports, researchers have established omphalitis as an adverse outcome associated with UCNS.8,10 To our knowledge, this is the first case associated with concomitant bacteremia and urinary tract infection. The true incidence of omphalitis associated with UCNS remains unknown, but our case now adds to those previously reported in the literature.
A previous study revealed a statistically significant association between omphalitis and unplanned home births (incidence 6.18% vs 1.05% in-home births versus in-hospital births, respectively [P < .001]). Presumably, these home births occurred in nonsterile conditions, thus raising the risk for infection.11 Theoretically, the practice of UCNS is nonsterile when compared to cord removal at the time of delivery, and thus it presents a similar risk for peripartum infection. Blood and urine cultures identified E coli as the causative bacterial etiology in this infant. More research is needed to describe the incidence of bacteremia and bacteriuria associated with UCNS. A recent investigation revealed that risk factors associated with early-onset neonatal E coli sepsis include premature birth, birth weight, and preterm, premature rupture of membranes12 ; UCNS may be an additional risk factor. Our infant was identified early in his course before any development of vital signs abnormalities or sepsis. In cases in which other risk factors for early-onset infection are present, a decision in favor of UCNS must consider the risks and benefits accordingly. It is unknown to what extent UCNS might further contribute to the risk of neonatal sepsis, but our case suggests risk is indeed present, even in the absence of other more common risk factors such as prematurity or low birth weight.
Alternative etiologies for this infant’s presentation must be considered. This infant was uncircumcised and could have developed a urinary tract infection with subsequent bacteremia; however, the appearance of the umbilicus with purulent exudate and erythema led us to favor omphalitis as the primary etiology. Additionally, the absence of pyuria and low urine colony count supports omphalitis as the primary etiology, rather than a primary urinary tract infection. Another potential mechanism for umbilical bacterial transmission would include the presence of a urachal remnant. Further workup for urachal abnormalities was not performed in this case but, if present, could provide an alternative route for his urinary tract infection. The positive blood culture does not exclude the potential for a urachal remnant, but hematogenous transmission from omphalitis through blood to the renal collecting system is our favored clinical scenario. The possibility of a urachal remnant should be considered with an abdominal ultrasound should this child have recurrent urinary tract infections or recurrent umbilical drainage.
Further investigation into risk of UCNS is necessary. Consensus opinion attributes no clear medical benefit to keeping the placenta attached.1 Thorough review of future cases must be performed to continue evaluating best-practice recommendations for UCNS. Our practice has been to implement a UCNS policy that includes recommendations on monitoring, guidance on what signs and symptoms to look for, and general management of the placenta. It has been suggested elsewhere that families electing UCNS in the hospital endorse such a protocol so that physicians caring for the infant are not only able to properly execute performance of this practice but also are protected from a medicolegal standpoint should complications arise.13 Implementation of a UCNS policy, however, did not prevent this patient from developing omphalitis. Pediatricians must collaborate with obstetricians and nurse midwives in creating hospital policies and educational materials about UCNS. Focused communication by maternal providers surrounding the risk of UCNS, with the ability to consult with pediatricians before birth, is advised for families electing UCNS. In addition to less severe conditions encountered in the neonatal period, such as hyperbilirubinemia, life-threatening infections can result from UCNS, and families must be counseled on these risks.
Conclusions
UCNS is an uncommon practice with minimal evidence-based research evaluating its safety. More information is needed on this topic to further evaluate the risk involved. Given the potential risk of serious bacterial infection with UCNS, providers are therefore tasked with communicating this risk to parents. Ultimately, this will lead to improved patient-centered care for families electing for UCNS.
Acknowledgments
We thank Dr Michael E. Watson, MD, PhD, Division of Pediatric Hospital Medicine and Division of Pediatric Infectious Diseases, University of Michigan, for his consultation in this clinical case description.
Drs Lanni and Panning conceptualized the case report, drafted the initial manuscript, and reviewed the final manuscript; Dr Spindler conceptualized the case report, performed analysis and interpretation of the data, drafted the initial manuscript, and critically reviewed and revised the final manuscript; Drs Monroe and Skoczylas performed analysis and interpretation of the data, critically revised the draft manuscript, and approved the final manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
FUNDING: No external funding.
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