Journal of Midwifery & Women’s Health

www.jmwh.org

Clinical Rounds

Umbilical Cord Avulsion in Waterbirth Robyn Schafer, CNM, MSN, EdM

Umbilical cord avulsion (or “cord snapping”) is often cited as a risk associated with waterbirth. This article discusses a case study in which a cord avulsed during a waterbirth and uses it as a basis to explore the incidence, etiology, and associated risk factors of umbilical cord avulsion. The diagnosis, clinical presentation, and management of cord avulsion in waterbirth is presented along with a thorough review of the literature and relevant professional standards. This article offers recommendations for clinical practice to minimize the risk of a cord avulsion and highlights the need for additional research and provider education to ensure optimal care of women and newborns. c 2014 by the American College of Nurse-Midwives. J Midwifery Womens Health 2014;59:91–94  Keywords: cord snapping, immersion, intrapartum emergencies, neonatal complications, umbilical cord avulsion, waterbirth

JM, a 27-year-old gravida 1 one para 0 at 37 and 4/7 weeks of gestation, presented to a birth center in active labor after spontaneous rupture of membranes. Her prenatal course and medical history were unremarkable. The first stage of labor lasted 5 hours with reassuring maternal and fetal status. JM desired a waterbirth, and after a 50-minute second stage in the tub, she had a normal spontaneous vaginal birth of a live female neonate. She gave birth in a hands-andknees position, with the newborn completely submerged underwater. The student nurse-midwife brought the newborn above the water surface, remarked that the umbilical cord was extremely short, and asked the mother to be careful as she transitioned to a forward-facing position. However, as soon as she was sitting upright, JM instinctively clutched her newborn up to her chest. The student nursemidwife heard a snapping sound, noticed a deep red gush of blood in the water, and stated to her preceptor that she thought the umbilical cord had avulsed. The certified nurse-midwife immediately directed JM to get out of the tub. As JM stood up holding her newborn, the umbilical cord was seen dangling, detached from the placenta. The certified nurse-midwife quickly clamped the newborn’s end of the cord, first with her fingers and then with a cord clamp, thus minimizing neonatal blood loss. The student nurse-midwife led JM out of the tub to the bed, grasped the maternal end of the umbilical cord at the introitus, and attached a cord clamp. The providers immediately performed a thorough assessment and determined that both the mother and newborn were in stable condition. Within minutes, the placenta delivered spontaneously with gentle cord traction and maternal pushing efforts. The placenta appeared grossly intact with a 3-vessel cord and normal configuration. Apgar scores were 8 and 9. A firstdegree laceration was repaired. Total estimated blood loss was 350 mL. There appeared to be no adverse sequelae resulting from the umbilical cord avulsion.

OVERVIEW OF WATERBIRTH

Stories of waterbirth date back to the ancient legends of Egypt and Crete and tribal stories of the Chumash Indians, Maoris, Samoans, and Hawaiians.1 Waterbirth made its first recorded appearance in an 1805 French medical journal2 and was later championed in the 1960s by Igor Charkovsky, a scientist and swim coach in the former Soviet Union. Waterbirth gained popularity through Fredrick Leboyer’s Birth Without Violence in 1975; Michel Odent’s3 publication of “Birth Under Water” in The Lancet in 1983; and widespread publicity by nurse, doula, and childbirth educator Barbara Harper, who founded the organization Waterbirth International in 1987. To date, there are no well-designed, sufficiently powered, randomized controlled trials that assess the risks and benefits of waterbirth,4–6 but it has been associated with improved pain relief, increased relaxation, greater sense of autonomy, reduced need for interventions or augmentation, and greater maternal satisfaction compared to land-based birth.3, 7–9 Some studies have also demonstrated a correlation with shorter duration of first and second stage of labor, reduced blood loss, and increased perineal integrity.9–12 Although risks associated with waterbirth appear to be rare, there are concerns of newborn hypoxic ischemic encephalopathy, maternal and neonatal infection, thermoregulation, water aspiration leading to neonatal hyponatremia and respiratory distress, and—the focus of this case study— umbilical cord avulsion (also known as cord “snapping” or “tearing”).13–15 REVIEW OF LITERATURE

Address correspondence to Robyn Schafer, CNM, MSN, 1973 Springfield Avenue, Maplewood, NJ 07040. E-mail: [email protected]

Although there are a few published studies on the subject of spontaneous antepartum or intrapartum umbilical cord rupture, none were found that examined the incidence, diagnosis, or management of cord avulsion outside the context of waterbirth. A 2009 Cochrane review5 on water immersion and birth also reported that no data on the incidence of cord avulsion in land-based birth were available. The incidence of cord avulsion in waterbirth has been reported in 3 retrospective studies and one prospective observational study (summarized in Table 1). Rosenthal16 reported 4 cord avulsions among 679 waterbirths at a birthing center

1526-9523/09/$36.00 doi:10.1111/jmwh.12157

c 2014 by the American College of Nurse-Midwives 

91

Table 1. Review of Literature: Cord Avulsion Incidence and Complications

Blood NICU Admission

Transfusion

After Cord

After Cord

Umbilical Cord

Avulsion in

Avulsion in

Avulsions, n

Waterbirth, n

Waterbirth, n

Waterbirths, n Rosenthal16

679

4

2

1

Gilbert and Tookey13

4032

≥ 5a

5

1

Cro and Preston17

100

4

1

1

Burns et al18

5192

18

≤ 3b

≤ 1b

3.10 (1.24–40)

1.09 (0.58–10)

0.40 (0.19–10)

Total Rate per 1000 (range)

Abbreviations: NICU, neonatal intensive care unit. a Gilbert and Tookey13 only report those cord avulsions that resulted in NICU admission. Rate and range calculations assume that there were 5 avulsions total in this study and exclude this data from NICU admission statistics. b Burns et al. 18 reported 20 umbilical cord avulsions, 18 of which occurred during waterbirth and 2 of which occurred in land-based birth. NICU admission and blood transfusion data are reported in relationship to all 20 avulsions. No details are provided regarding whether these outcomes were associated with land-based or waterbirth. Rate and range calculations assume that all 18 occurred during waterbirth.

that occurred “when the mother lifted the infant rapidly from the water.” Two newborns were hospitalized for anemia secondary to “delayed recognition of bleeding from torn umbilical cords,” and one newborn required a blood transfusion due to a “prolonged delay” in diagnosing the avulsion. Gilbert and Tookey’s13 review of 4032 waterbirths found 5 cases of admission to a neonatal intensive care unit (NICU) due to avulsed umbilical cords, with no additional data provided on the total number of cord avulsions. Of those NICU admissions, one newborn required a transfusion; one newborn developed hypoxic ischemic encephalopathy grade 2; and one newborn was diagnosed with a chromosomal abnormality. The authors concluded that waterbirth does not substantially increase adverse perinatal outcomes among low-risk women; however, they noted that the study size was too small to make conclusions about whether certain risks such as umbilical cord avulsion occur less frequently in land-based birth. Cro and Preston’s17 audit of 100 waterbirths reported 4 cases of cord avulsion. In 3 of those cases, the avulsion was recognized immediately, and the newborns had no adverse effects. In the fourth case, in which recognition of the avulsion was delayed, the newborn required NICU admission and a blood transfusion. Burns et al.18 examined 8924 low-risk women with access to water immersion and birth. The study resulted in 7915 spontaneous births, including 5192 waterbirths and 20 umbilical cord avulsions (18 of which occurred in the water and 2 of which occurred on land). Of those 20 cases, 3 newborns were admitted to NICUs and one required a blood transfusion; no data were provided specifying whether these outcomes were associated with land-based or waterbirth. The authors of this study reported that the overall waterbirth setting (ie, hospital, birth center, or home) did not appear to affect neonatal outcomes. In addition to these studies, some individual case reports19, 20 of cord avulsions in waterbirth have been published, as well as several editorials and letters21–24 discussing the diagnosis of an avulsion and preventative measures. Based on the pooled data of these studies, the overall incidence of reported cord avulsion in the published literature appears to be approximately 3.10 per 1000 waterbirths, with 92

roughly 23% of cases of cord avulsions leading to NICU admission, 13% of cases leading to neonatal hemorrhage requiring a transfusion, and no reports of any long-term adverse effects. No studies found any correlation between umbilical cord avulsion and maternal morbidity or neonatal mortality. ETIOLOGY OF CORD AVULSION

The suspected cause the apparent increased risk of cord avulsion in waterbirth is that there may be a strong instinct to bring the newborn above the surface of the water immediately after birth. This can translate into rapid cord traction over a distance greater than in land-based birth, without respect for cord length or tension. Specifically, mothers or providers may overstretch and avulse umbilical cords that are not long enough to reach above the water surface or may apply undue traction by lifting the newborn too quickly.13, 22 Midwives have proposed alternative etiologies such as altered turgor pressure of the cord—resulting directly from cord immersion in warm water or indirectly through changes in maternal hormones associated with water immersion—but these theories have not been widely supported.23, 24 RISK FACTORS AND DIAGNOSIS

Cited risk factors for cord avulsion in both land-based and waterbirth include umbilical cord abnormalities such as hematomas, tumors, limited length, abnormal insertion in the placenta, and operative birth (ie, cord trauma).20 Specifically in waterbirth, maternal positioning and water depth may be additional risk factors, although further research is needed to support this claim. The diagnosis of cord avulsion in waterbirth is based on the following typical clinical presentation:17, 19–22 dramatic change in the color of the water to deep red due to a sudden gush of blood; snapping sound when lifting the newborn out of the water; sudden release of cord tension; visualization of a detached cord; and signs of neonatal hemorrhagic shock (eg, pallor, respiratory distress, bradycardia). Because diagnosis of a cord avulsion is based on clinical presentation, there is a concern that the visual impediment of the water may delay recognition and management. In one Volume 59, No. 1, January/February 2014

case study of a newborn admitted to a NICU following a cord avulsion, the authors proposed that the turbid water following birth impaired the midwife’s ability to visualize the detached cord and ensuing blood loss, leading to hemorrhagic shock.19

Table 2. Recommendations for Clinical Practice to Reduce the Risk of Umbilical Cord Avulsion and Associated Morbidities in Waterbirth

MANAGEMENT

Lower the water level before the birth to reduce the distance

Recognize the potential for an umbilical cord avulsion and be familiar with its typical presentation.

When a cord avulsion is diagnosed, appropriate management should prioritize the serious risk of neonatal hemorrhage. Therefore, the midwife should immediately clamp the newborn’s end of the umbilical cord to minimize blood loss and assess the newborn for any signs of shock. If the newborn displays any abnormal vital signs or other signs of distress, consultation with neonatology is recommended—necessitating a transfer if the birth occurred in an out-of-hospital setting. Once the newborn has been assessed and deemed stable, the midwife can proceed with management of third stage. It is not critical to clamp the maternal end of the umbilical cord; although, if left unclamped, proper universal safety precautions should be taken to protect providers from contact with any splattered blood. If the maternal end of the cord is visible externally or can be easily reached internally, it may be grasped for controlled cord traction. If the cord is not reachable or if physiologic management of third stage is preferred, the midwife may direct the woman to assist with expulsion of the placenta (eg, upright positioning, maternal pushing efforts). If unsuccessful, manual removal of the placenta may be necessary.

evaluating birth outcomes. These data are necessary to accurately determine the incidence of cord avulsion in waterbirth and to gather comparable data for land-based birth.

DISCUSSION

Position Statements

The lack of research about cord avulsions in land-based birth may be due to the fact that, out of the water, cord avulsions typically occur during controlled cord traction in third stage when the umbilical cord has already been clamped and the risk for morbidity is quite low. Whereas in waterbirth, cord avulsions typically occur when the newborn is lifted above the water surface, still attached to the cord and at risk for hemorrhage. Because the etiology of cord avulsion appears to be iatrogenic (eg, provider practice) or strongly associated with environmental factors (eg, depth of water, maternal positioning), rates of incidence may vary widely. Accordingly, provider education regarding the risk of cord avulsion is essential to reduce its incidence. Moreover, because the risk of neonatal morbidity appears to be in direct correlation to the duration of time between the occurrence of the avulsion and its management, measures to ensure prompt diagnosis and treatment are critical. As Sheila Kitzinger21 states, a cord avulsion is “not an emergency for a skilled midwife” because, as case studies show, the risk of neonatal morbidity is quite low when providers respond with prompt, appropriate management.

The American Academy of Pediatrics and the American College of Obstetricians and Gynecologists25 have jointly stated that there is insufficient evidence demonstrating the benefits of waterbirth and cite the potential risk for neonatal complications (including umbilical cord avulsion) as rationale to limit the scope of waterbirth to randomized controlled trials— presumably until its safety can be more firmly established. The American College of Nurse-Midwives has no official position on waterbirth and offers no guidelines for its practice. The Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives26 have jointly concluded that, even without high-quality evidence, “Women who make an informed choice to give birth in water should be given every opportunity and assistance to do so by attendants who have appropriate experience” and encourage facilities to provide systems and structures to support safe waterbirth. They consider umbilical cord avulsion a clinically significant risk associated with waterbirth and recommend that all waterbirth providers undergo training on emergent management of an avulsion.

Implications for Clinical Practice

Evaluation of Case Study

Providers who offer waterbirth should be educated about the potential for cord avulsion, its risk factors, presentation, and appropriate management. Measures that may reduce the incidence of cord avulsion and its associated risks are listed in Table 2. Facilities may wish to include data about cord avulsion and associated neonatal morbidities in auditing processes for

In the clinical scenario cited here, the student nurse-midwife was aware of the possibility of a cord avulsion, identified the risk factor of a short umbilical cord, cautioned the mother about excessive cord traction, and immediately recognized the clinical presentation (ie, snapping sound, visible release of cord tension, and gush of deep red blood in the water). The

Journal of Midwifery & Women’s Health r www.jmwh.org

that the cord must extend (being careful not to lower it to a level that decreases maternal comfort or increases the likelihood of the newborn being exposed to air and resubmerged under water). Have cord clamps immediately available. Bring the newborn to the water surface gently, avoiding excessive cord traction. Perform a thorough examination of the newborn and umbilical cord immediately following the birth. Understand the need for prompt recognition and treatment to reduce the risk of neonatal hemorrhage and associated morbidity.

93

providers were prepared with cord clamps within reach. The certified nurse-midwife responded appropriately by clamping the newborn’s end of the umbilical cord promptly, directing the mother out of the tub, and performing a thorough assessment—thus resolving the situation without compromising the health of the newborn. In this way, a prepared and knowledgeable team was able to honor the woman’s desire for a safe waterbirth and to deal effectively with a cord avulsion, avoiding any adverse outcomes. CONCLUSION

Waterbirth may be associated with an increased risk of umbilical cord avulsion compared to land-based birth. There is insufficient research to accurately determine the rate of neonatal morbidity following cord avulsion in waterbirth, although the overall rate appears to be quite low. In the small number of underpowered studies and case reports published on this topic, the risk of neonatal hemorrhage appears to be strongly correlated with a lack of prompt recognition and management of an avulsion. With increased provider and patient education about the risk of cord avulsion and simple preventative measures as outlined here, the incidence of cord avulsion and associated morbidities can be greatly reduced. Additional research into umbilical cord avulsion, both in and out of the water, is necessary to develop safe, evidence-based practice guidelines to ensure that providers are able and adequately prepared to honor women’s choices and provide optimal care in labor and birth. AUTHOR

Robyn Schafer, CNM, MSN, EdM, is in a full-scope, collaborative practice in Maplewood, New Jersey, and is a recent graduate of Yale University School of Nursing. CONFLICT OF INTEREST

The author has no conflicts of interest to disclose. REFERENCES 1.Garland D. Revisiting Waterbirth: An Attitude to Care. New York, NY: Palgrave Macmillan; 2011. 2.Embry M. Observations sur un accouchement termine dans le bain. Les Annales de la Societe de Medicine Pratique de Montpelier. 1805;185–191. 3.Odent M. Birth under water. Lancet. 1983;2(8365–66):1476-1477. 4.McCandlish R, Renfrew M. Immersion in water during labor and birth: The need for evaluation. Birth. 1993;20(2):79-85. 5.Cluett ER, Burns E. Immersion in water in labour and birth. Cochrane Database Syst Rev. 2009; (2): CD000111. 6.Simpson KR. Underwater birth. J Obstet Gynecol Neonatal Nurs. 2013;42(5):588-594.

94

7.Otigbah CM, Dhanjal MK, Harmsworth G, Chard T. A retrospective comparison of water births and conventional vaginal deliveries. Eur J Obstet Gynecol Reprod Biol. 2000;91(1):15-20. 8.Richmond H. Women’s experience of waterbirth. Pract Midwife. 2003;6(3):26-31. 9.Geissbuehler V, Stein S, Eberhard J. Waterbirths compared with landbirths: An observational study of nine years. J Perinat Med. 2004;32:308-314. 10.Zanetti-Daellenbach RA, Tschudin S, Zhong XY, Holzgreve W, Lapaire O, Hosli I. Maternal and neonatal infections and obstetrical outcome in water birth. Eur J Obstet Gynecol Reprod Biol. 2007;134(1):37-43. 11.Dahlen HG. Maternal and perinatal outcomes amongst low risk women giving birth in water compared to six birth positions on land. A descriptive cross sectional study in a birth centre over 12 years. Midwifery. 2013;29(7):759-764. 12.Menakaya U, Albayati S, Vella E, Fenwick J, Angstetra D. A retrospective comparison of water birth and conventional vaginal birth among women deemed to be low risk in a secondary level hospital in Australia. Women and Birth. 2013;26(2):114-118. 13.Gilbert RE, Tookey PA. Perinatal mortality and morbidity among babies delivered in water: Surveillance study and postal survey. British Medical Journal. 1999;319(7208):483-487. 14.Pinette M, Wax J, Wilson E. The risks of underwater birth. Obstet Gynecol. 2004;190(5):1211-1215. 15.Young K, Kruske S. How valid are the common concerns raised against water birth? A focused review of the literature. Women Birth. 2013;26(2):105-109. 16.Rosenthal MJ. Warm-water immersion in labor and delivery. Female Patient. 1991;16(8):35-46. 17.Cro S, Preston J. Cord snapping at waterbirth delivery. Br J Midwifery. 2002;10(8):494-497. 18.Burns EE, Boulton MG, Cluett E, Cornelius VR, Smith LA. Characteristics, interventions, and outcomes of women who used a birthing pool: A prospective observational study. Birth. 2012;39(3):192202. 19.de Graaf JH, Meringa MP, Zweens MJ. Severe blood loss in a neonate due to a ruptured umbilical cord in a bath delivery. BMJ Rapid Responses. 25 February 2000. http://www.bmj.com/rapid-response/ 2011/10/28/severe-blood-loss-neonate-due-ruptured-umbilical-cordbath-delivery. 20.Kalf K, Hochstrasser L, Lapaire O, Hegi L, Benzing J, Hosli I. Severe neonatal blood loss due to umbilical cord rupture in an underwater birth. Z Geburtshilfe Neonatol. 2011;215(1):41-44. 21.Kitzinger S. Letter from Europe: The waterbirth debate up-to-date. Birth. 2000;27(3):214-216. 22.Anderson T. Umbilical cords and underwater birth. Pract Midwife. 2000;3(2):12. 23.Slome J. Letters: Cord snapping at waterbirth. Br J Midwifery. 2002;10(11):668. 24.Strickland S. Letters: Cord snapping at waterbirth. Br J Midwifery. 2003;11(7):430-431. 25.American Academy of Pediatrics, American College of Obstetricians and Gynecologists. Guidelines for perinatal care. 7th ed. Elk Grove Village, IL: AAP/ACOG; 2012. 26.Royal College of Obstetricians and Gynaecologists and Royal College of Midwives. Joint statement No1: Immersion in water during labour and birth. http://www.rcog.org.uk/womens-health/ clinical-guidance/immersion-water-during-labour-and-birth; 2006.

Volume 59, No. 1, January/February 2014

Umbilical cord avulsion in waterbirth.

Umbilical cord avulsion (or "cord snapping") is often cited as a risk associated with waterbirth. This article discusses a case study in which a cord ...
125KB Sizes 8 Downloads 3 Views