Coronial
VIChospital

Finding into death of Baby S

Demographics

female

Date of death

2017-08-16

Finding date

2020-05-21

Cause of death

Sepsis in the setting of a lotus birth

AI-generated summary

A premature female neonate born at 36+5 weeks via emergency caesarean section developed sepsis and died at 2 days of age. She had been delivered with lotus birth (cord left attached to placenta) and vaginal seeding (maternal vaginal fluid applied to baby) despite obstetric counselling against these practices. Her mother's GBS status was unknown and she declined antibiotics and antenatal steroids. The infant showed early signs of sepsis at SCN admission (hypoglycaemia, hypothermia, poor perfusion, mottled appearance) but improved initially. She deteriorated on day 2 with grunting, pallor, and hypothermia; antibiotics were started promptly. Despite aggressive resuscitation and retrieval to a tertiary centre, she died from sepsis with evidence of early necrotising enterocolitis and umbilical cord inflammation. Key lessons: alternative birth practices (lotus birth, vaginal seeding) carry significant infection risk, particularly when maternal GBS status is unknown; early recognition of sepsis signs in high-risk neonates is critical; all relevant clinical information must be communicated between obstetric and paediatric teams; and clear guidelines for counselling parents about non-evidence-based practices are essential.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.

Contributing factors

  • Lotus birth (umbilical cord nonseverance)
  • Vaginal seeding with unknown maternal GBS status
  • Mother declined GBS screening
  • Mother declined intrapartum antibiotic prophylaxis
  • Mother declined antenatal steroids
  • Prematurity (36+5 weeks)
  • Low birth weight (2070g)
  • Early necrotising enterocolitis
  • Foetal peripartum umbilical cord infection
  • Delayed awareness of vaginal seeding by paediatric team
  • Lack of hospital policy on lotus birth and vaginal seeding at time of birth

Coroner's recommendations

  1. Safer Care Victoria Maternity and Newborn Clinical Network groups should formulate clinical practice guidelines or consensus statements regarding lotus birth and vaginal seeding in consultation with RANZCOG, the Consultative Council of Obstetric and Paediatric Mortality and Morbidity, and other relevant experts.
  2. Eastern Health services should institute a review of new or alternative practices by a clinically relevant hospital committee, which includes experienced senior medical staff, to thoroughly assess new or alternative practices for their risks and evidence basis and ultimately approve whether the new practice should be allowed to proceed.
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