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

org
Clinical Rounds

Neonatal Omphalitis After Lotus Birth

Courtney Steer-Massaro1 , CNM, FNP-C, RN, MPH

Lotus birth, or umbilical nonseverance, is the practice wherein the umbilical cord is not separated from the placenta after birth, but allowed instead
to dry and fall off on its own. Lotus birth may result in neonatal omphalitis. This article describes the history and rationale for lotus birth as well as
the etiology, incidence, clinical presentation, and management of neonatal omphalitis. Recommendations for educating families how to perform
lotus birth safely are presented. Additionally, signs and symptoms that warrant newborn assessment and treatment are reviewed.
J Midwifery Womens Health 2020;00:1–5  c 2020 by the American College of Nurse-Midwives.

Keywords: lotus birth, umbilical nonseverance, neonatal omphalitis

CASE SUMMARY
C.P., a 23-year-old, gravida 3 para 2, presented to a hos-
pital setting at 41 weeks’ and 2 days in active labor. C.P.
had no history of medical disorders or surgery. Her preg-
nancy course was uncomplicated, with the exception of be-
ing vaginally colonized with group B Streptococcus. C.P.
had declined to have laboratory tests performed before 36
weeks’ gestation because of belonging to a religious group
that declined collection of blood samples, vaccines, or any
pricking of the skin, with the exception of emergencies. She
hoped to have a birth that was as noninterventional as pos-
sible, and also planned a lotus birth.
C.P.’s vaginal examination on admission revealed cer-
vical dilatation of 8 cm with 90% effacement, and the fetus
was vertex and at −1 station. C.P. reported spontaneous
rupture of membranes of clear fluid approximately one
hour earlier at home. She quickly progressed to 10 cm
dilatation and had an uncomplicated vaginal birth. The
newborn weighed 3260 g, had Apgar score of 9/9 at one
and 5 minutes, and breastfed within the first hour of life.
Per C.P.’s request, after birth the umbilical cord was not
clamped or cut. After completion of the third stage of
labor, the placenta was put in a hospital-issued plastic
bucket to allow it to stay close to the newborn.
On day of life one, the newborn was noted to have
a 1.5-cm circumferential area of erythema surrounding
the umbilicus. A pediatric infectious disease physician
was consulted. The physician recommended starting
antibiotic therapy because of a concern for omphalitis.
This recommendation was discussed with C.P. At that
time she declined initiation of antibiotics or cutting the
umbilical cord, so the plan was to perform serial exami-
nations with continued close monitoring of her newborn.
1 birth chimpanzees do not always separate their placentas
Department of Obstetrics and Gynecology, Boston University
School of Medicine, The Midwives at Boston Medical Center,
Boston, Massachusetts
Correspondence
Courtney Steer-Massaro
Email: courtney.massaro@bmc.org
ORCID
Courtney Steer-Massaro https://orcid.org/0000-0002-0036-2824
Throughout that day, the newborn remained afebrile and
hemodynamically stable. On the morning of postpartum
day 2, the omphalitis was noted to have spread to 2 to 3
cm superior to the umbilicus and 1.5 cm inferior to the
umbilicus, with a superficial fullness above the umbilicus
and tenderness. Because of concerns of a worsening infec-
tion, C.P. agreed to separate the umbilical cord from the
placenta and initiate antibiotic treatment for her newborn.
An intravenous line was placed, blood cultures and a
complete blood count with differential were obtained, and
ampicillin, gentamicin, and clindamycin were started. The
newborn remained afebrile and hemodynamically stable
throughout the course of a 10-day treatment of antibiotics
and had resolution of the erythema.
Blood cultures showed no growth by the fifth day
postpartum. No umbilical cord cultures, neither neonatal
nor placental, were collected. The placenta was not sent to
pathology, as C.P. brought it home with her upon discharge.
INTRODUCTION
Lotus birth, or umbilical nonseverance, is the practice
whereby the umbilical cord is not cut from the placenta fol-
lowing birth but is, instead, allowed to dry and fall off on its
own.1,2 There is limited and conflicting information about the
safety of lotus births.3–6 Omphalitis is a localized infection of
the umbilicus primarily affecting neonates. Although compli-
cations of omphalitis are rare, they can be devastating, primar-
ily in developing nations where access to treatment is not al-
ways readily available.7,8 Theoretically, the risk of omphalitis
is increased when the newborns exposure to the placenta is
prolonged after birth, as occurs during a lotus birth.5
The term lotus birth is named after Clair Lotus Day,
who, while pregnant in 1974, questioned routine umbilical
cord clamping. She did so because of her awareness that after
from their newborns. She transferred such a model to human
birth.1,9 Although reasons for having a lotus birth vary, those
cited include honor to the placenta, acknowledgment of the
perceived connection between the newborn and the placenta,
belief that the newborn knows the time for the placenta to
be released, and increased attachment behavior and bonding
between mother and newborn.1,5,10–12

1526-9523/09/$36.00 doi:10.1111/jmwh.13062 
c 2020 by the American College of Nurse-Midwives 1
 There are no published data about the frequency of lotus
births either in the United States or internationally. To effect a
lotus birth, the placenta is typically washed and cleaned with
water and dried thoroughly. It can then be covered in a mix-
ture of salts and/or herbs to decrease odor and bacterial grown
and facilitate drying. Finally, the placenta is often wrapped
in an air permeable cloth until the umbilical cord natu-
rally disintegrates. This process can take approximately 3 to
10 days.1–3,9
Because of the potential risk of infection associated with
lotus birth, the Royal College of Obstetricians and Gyne-
cologists issued a statement advising against the practice.13
No other national organization, including the American
College of Nurse-Midwives, has issued statements specifically
regarding lotus births. Many national and international
organizations discuss the value of delayed cord clamping
and appropriate cord care after such clamping, although no
current guidelines discuss umbilical care if the cord is not
clamped, as in a lotus birth.14–18
CLINICAL OUTCOMES ASSOCIATED WITH LOTUS
BIRTH
Research on clinical outcomes associated with lotus births is
limited to published case reports (Table 1). A total of 4 pub-
lished case reports were found that presented 13 instances of
lotus birth. The techniques for handling the placenta varied.
Zinsser reported the outcomes of 3 cases of lotus birth
in out-of-hospital settings, and none had adverse outcomes.3
Likewise, Monroe et al. documented 6 in-hospital lotus births
in which no neonatal infections were noted.5
In contrast, 4 adverse outcomes were reported by Tri-
carico et al and Ittleman et al.4,6 Tricarico et al described
an out-of-hospital birth wherein the newborn was admit-
ted shortly after birth because of jaundice, which improved
with cord separation and phototherapy. On day of life 25, the
newborn was readmitted because of poor responsiveness and
jaundice and was diagnosed with idiopathic newborn hepati-
tis. The newborn’s symptoms improved without intervention.4
The first case reported by Ittleman et al was of a newborn who
developed Staphylococcus lugdunensis endocarditis, neces-
sitating intravenous antibiotics for 6 weeks. The second case
involved a newborn with hyperbilirubinemia and persistent
tachycardia. The tachycardia resolved after the initial dose of
antibiotics, and the hyperbilirubinemia resolved after breast-
feeding and phototherapy. The third newborn developed
neonatal omphalitis, which was initially expectantly managed
with umbilical cord severance, until worsening symptoms de-
veloped, then antibiotics were administered for 7 days.6
NEONATAL OMPHALITIS
After birth, necrosis of the umbilical cord occurs because
of thrombosis and contractions of the umbilical vessels.18
The umbilical tissue is substrate rich, and when devitalized,
it is prone to bacterial colonization. Such colonization can
come from either the maternal genital tract or from the en-
vironment soon after birth.6,7,19 Any resulting cord infections
can delay or prevent the normal process of umbilical vessel
deterioration and separation, thus allowing bacteria direct ac-
cess to the newborn circulation.8,20
2 Volume 00, No. 0, xxxx 2020
It is estimated that the in-hospital incidence of newborn
omphalitis in the developed world is approximately 1 per
1000 term births, whereas the rate is much higher in de-
veloping countries.7 The organisms responsible for omphali-
tis vary by geographical locations. Staphylococcus aureus,
Staphylococcus epidermidis, groups A and B Streptococci,
Escherichia coli, Klebsiella, Pseudomonas, and Clostrid-
ium difficile are the most common pathogens in the devel-
oped world.8
There are 4 grades of neonatal omphalitis based on
severity: 1) funisitis or umbilical discharge, an unhealthy-
appearing cord with purulent, malodorous discharge; 2) om-
phalitis with abdominal wall cellulitis, periumbilical ery-
thema, and tenderness in addition to an unhealthy-appearing
cord with discharge; 3) omphalitis with systemic signs of in-
fection; and 4) omphalitis with necrotizing fasciitis, frequently
associated with signs and symptoms of overwhelming sepsis
and shock.7
Complications associated with omphalitis include
septicemia, necrotizing fasciitis, abscesses, hepatic com-
plications, infection of the urachal remnant, peritoneal
complications, and spontaneous bowel evisceration.8,19,20
When complications of omphalitis occur, they can quickly
progress to systemic infection and death.8,19,20
Neonatal omphalitis is treated with broad spectrum
parenteral antibiotics, directed against both Gram-negative
and Gram-positive organisms.19 Empiric treatment with
antistaphylococcal penicillin and aminoglycoside is recom-
mended to decrease significant complications such as sepsis
and necrotizing fasciitis.19 Vancomycin should be used in-
stead of antistaphylococcal penicillin in communities with a
high prevalence of methicillin-resistant S. aureus. Addition-
ally, to treat anaerobes, clindamycin (Cleocin) or metronida-
zole (Flagyl) are suggested if the umbilical cord is foul smelling
or the newborn’s mother had intraamniotic infection.19 The
duration of antibiotic therapy is dependent on the newborn’s
clinical response and any complications that develop during
treatment.18 In the case of uncomplicated omphalitis, par-
enteral therapy for 10 days is recommended, followed by oral
therapy depending on culture results.19 Necrotizing fasciitis
should be suspected if there is no clinical improvement
after 24 to 48 hours of intravenous antibiotics. In the case
of suspected necrotizing fasciitis, surgical debridement of
the umbilical structures and any involved abdominal wall is
vital.19
Prevention of Neonatal Omphalitis
To prevent omphalitis, the World Health Organization recom-
mends that newborns born in a hospital or in settings of low
mortality should have dry cord care (ie, the umbilical cord is
clamped and cut without application of topical substances to
the severed cord).21 A 2015 Cochrane review supported these
guidelines, finding insufficient evidence to support antisep-
tic application to the umbilical cord in developed countries.
Additionally, the Cochrane review did not find any antisep-
tic that was “convincingly” advantageous compared with dry
cord care in relation to reducing the incidence of omphalitis.22
A systematic review published in 2018 assessed the value of
topical application of human breast milk to cord separation
 Table 1. Review of Lotus Birth Case Reports
Author Description of Lotus Births Outcomes
3
Zinsser 3 out-of-hospital vaginal births The umbilical cord separated spontaneously on
2018 Placenta preparation: washed with water, covered postpartum day 6 in all 3 infants
with salt and herbs (dry lavender flowers and No adverse outcomes were noted
lotus placenta neem), wrapped in cotton layer
and a second layer of Molten. Salting was
repeated daily as needed.
5
Monroe et al 6 in-hospital births: 1 unplanned cesarean birth, Three families cut the umbilical cord before it
2019 1 vaginal waterbirth and 4 non-water vaginal separated on its own (2 on day of life 2, 1 on
births day of life 3). The other 3 separated on day 5, 7,
Placenta preparation varied: 4 families applied and 10, respectively
salt and herbs, 1 wrapped it in a diaper, 1 kept No adverse outcomes were noted
it a small container at the bedside
Tricarico et al4 1 out-of-hospital birth vaginal birth Idiopathic newborn hepatitis, treated initially
2017 No description of how lotus birth was handled with cord separation and phototherapy.
Readmission on day of life 25 because of poor
responsiveness and jaundice, mildly enlarged
liver found, which improved without
intervention
6
Ittleman et al 3 births: one out-of-hospital waterbirth and 2 Case 1: Staphylococcus lugdunensis
2019 in-hospital non-waterbirths endocarditis treated with IV vancomycin
No description of how lotus births were handled treatment for 10 days and 6 weeks of IV
nafcillin
Case 2: hyperbilirubinemia and persistent
tachycardia, tachycardia resolved after the
initial dose of ampicillin and gentamicin,
hyperbilirubinemia after breastfeeding and
phototherapy
Case 3: neonatal omphalitis after birth notable for
maternal tachycardia without fever and
prolonged rupture of membranes, treated with
IV ampicillin and gentamicin for 7 days

Abbreviation: IV, intravenous.

time and omphalitis rates.23 This study analyzed the results
of 6 randomized controlled trials (n = 1022 newborns who
were born in hospitals). The authors found application of
breast milk significantly reduced cord separation time com-
pared with dry cord care (P ⬍ .001), with the mean difference
of −1.01 day (95% CI, −1.33 to −0.69).23 No significant dif-
ference was found in omphalitis between the treatment groups
(risk ratio, 0.82; 95% CI, 0.57-1.18; P = .29).23
DISCUSSION
There is limited research that clearly identifies complications
associated with lotus births; however, it is likely that this case
of neonatal omphalitis resulted from the prolonged contact
with known vectors of infection, including the umbilical cord
and placenta. In C.P.’s case, her newborn was demonstrating
signs of a grade 2 infection, and prompt antibiotic treatment
was the recommendation for treatment. Her clinicians
recommended separation of the placenta to disconnect the
newborn from the probable source of infection. The newborn
received the appropriate broad spectrum antibiotics and
close monitoring to ensure no worsening of symptoms. C.P.’s
newborn had a rapid resolution of the omphalitis related
symptoms.
Although lotus births are not common, midwives and
other perinatal and neonatal care providers should be aware
of this possible birth choice. Shared decision making discus-
sions about the benefits, as well as the possible risks, can help
families best prepare for procedures that might be indicated.
Shared decision making throughout pregnancy was important
in this case. C.P. had multiple, well documented, discussions
with her prenatal provider about her plans for labor, as well
as her desire for a lotus birth. These discussions helped the
midwife who cared for her in labor to understand her birth

Journal of Midwifery & Women’s Health r www.jmwh.org 3

 Table 2. Signs in a Newborn Having a Lotus Birth that Warrant
Immediate Assessment
Warning Signs
Any redness, warmth, swelling at or around the umbilical
area
A temperature greater than 100.4ºF
Sleeping more than usual
Poor feeding: in a newborn 24-48 hours of life, fewer than
6-8 feedings, with fewer than 2 urines and 2 stools; in a
newborn 49-72 hours of life: fewer than 8-12 feedings per
day, with fewer than 3 urine and 3 stools
Adapted from University of Michigan C.S. Mott Children’s Hospital Department of
Pediatrics’ lotus birth/umbilical non-severance policy.24
plan and use those prenatal discussions as a starting point for
her in-patient counseling. Additionally, given C.P.’s religious
beliefs, she at first was not ready to end the lotus birth and
subject her newborn to blood collection and intravenous an-
tibiotics. As a result, she spoke with a multidisciplinary team
a number of times to ensure bidirectional discussions about
her newborn’s care. Despite the hospital team’s concerns, her
beliefs and wishes were initially honored with not starting an-
tibiotics or separating the placenta and then, when the new-
borns infection worsened, by allowing her to dictate when the
umbilical cord was finally separated.
There is unfortunately no evidence-based information
about the safest way to perform a lotus birth. Nonetheless,
families who want to have a lotus birth should be educated
about basic hygiene recommendations and placental care op-
tions. Washing hands with soap before touching the umbili-
cal cord or placenta will help decrease spread of infection.21
Additionally, the placenta should be washed with water to re-
move any blood or blood clots and dried well.1,3,9 Although
the placenta can be washed within the first 24 hours, it is ad-
vised to perform this task within the first hours after birth to
force dehydration.2 Suggestions of how to dry the placenta in-
clude initially placing it in a colander to drain and then wrap-
ping it in a cloth of natural fibers not only to allow it ex-
posure to air but for the cloth to absorb extra moisture.1,3,9
Various herbs as well as salt placed on the placenta have
also been proposed to help prevent bacterial growth, control
smell, and enhance drying.1,3,9 As the umbilical cord dries it
becomes brittle and eventually separates on its own.1,3,9 Al-
though not mentioned in the lotus birth literature, it appears
that the application of breast milk to the umbilical cord could
be an additional option to help decrease the cord separation
time.23
Signs and symptoms of complications of a lotus birth
should be closely assessed by perinatal care providers doing
newborn exams and reviewed with families. Table 2 lists
warning signs that would warrant the newborn needing
immediate health assessment.24 Continued research needs
to be conducted to provide more literature evaluating all
aspects of lotus births. This research should look at not only
how most safely to perform a lotus birth but the positive and
negative aspects associated with this type of birth.
4 Volume 00, No. 0, xxxx 2020
CONCLUSION
It seems plausible that this case of neonatal omphalitis was
made more likely by delayed detachment of the placenta and
umbilical cord from the newborn’s umbilicus. The lotus birth
may have created an ideal breeding ground for infection given
the tissue ischemia and prolonged attachment of the umbili-
cal cord and placenta. Although the incidence of lotus birth
and associated complications are not well known, awareness
of neonatal omphalitis and how to diagnose and treat this in-
fection is an important component of care for women who
chose this option.
CONFLICT OF INTEREST
The author has no conflicts of interest to disclose.
ACKNOWLEDGMENTS
The author would like to thank Dr. Tina Yarrington for her
thoughtful feedback on this topic.
REFERENCES
1.Buckley SJ. Lotus birth: a ritual for our times. Midwifery Today Int
Midwife. 2003;67:36-38.
2.Monroe KK, Rubin A, Mychaliska KP, Skoczylas M, Burrows HL. Lo-
tus birth: a case series report on umbilical nonseverance. Clin Pediatr.
2019;58(1):88-94.
3.Zinsser LA. Lotus birth, a holistic approach on physiological cord
clamping. Women Birth. 2018;31(2):e73-e76.
4.Tricarico A, Bianco V, Di Biase AR, Lughetti L, Ferrari F, Berardi
A. Lotus birth associated with idiopathic neonatal hepatitis. Pediatr
Neonatol. 2017;58(3):281-282.
5.Monroe KK, Rubin A, Mychaliska KP, Skoczylas M, Burrows HL. Lo-
tus birth: a case series report on umbilical nonseverance. Clin Pediatr.
2019;58(1):88-94.
6.Ittleman BR, German KR, Scott E, et al. Umbilical cord nonseverance
and adverse neonatal outcomes. Clin Pediatr. 2019;58(2):238-240.
7.Stewart D, Benitz W; Committee on Fetus and Newborn. Umbilical
cord care in the newborn infant. Pediatrics. 2016;38(3):e20162149.
8.Fraser N, Davies BW, Cusack J. Neonatal omphalitis: a review of its
serious complications. Acta Paediatr. 2006;95(5):519-522.
9.Buckley SJ. Gentle Birth, Gentle Mothering. Anstead, Queensland,
Australia: One Moon Press; 2006.
10.Hastie C, Fahy KM. Optimising psychophysiology in third stage of
labour: theory applied to practice. Women Birth. 2009;22(3):89-96.
11.Bonsignore A, Buffelli F, Ciliberti R, Ventura F, Molinelli A, Fulcheri E.
Medico-legal considerations on “Lotus Birth” in the Italian legislative
framework. Ital J Pediatr. 2019;45(1):39.
12.Royal College of Obstetricians and Gynecologists. RCOG Statement
on Umbilical on Umbilical Non-Severance or “Lotus Birth”.
https://www.rcog.org.uk/en/news/rcog-statement-on-umbilical-non-
severance-or-lotus-birth/. 2008. Accessed September 1, 2018.
13.Burns E. More than clinical waste? Placenta rituals among Australian
home-birthing women. J Perinat Educ. 2014;23(1):41-49.
14.World Health Organization. Guideline: Delayed Umbilical Cord
Clamping for Improved Maternal and Infant Health and Nutrition
Outcomes. Geneva, Switzerland: World Health Organization, 2014.
https://apps.who.int/iris/bitstream/handle/10665/148793/978924150
8209_eng.pdf?ua=1. Accessed September 1, 2018.
15.American College of Nurse-Midwives. Delayed Umbilical Cord
Clamping. Silver Spring, MD: American College of Nurse-Midwives,
2014. http://www.midwife.org/ACNM/files/ACNMLibraryData/UPL
OADFILENAME/000000000290/Delayed-Umbilical-Cord-Clamp
ing-May-2014.pdf. Accessed January 23, 2019.
16.American College of Obstetricians and Gynecologists. Committee
opinion no. 684: delayed umbilical cord clamping after birth. Obstet
Gynecol. 2017;129(1):e5-e10.
17.Lee L, Dy J, Azzam H. Management of spontaneous labour at term in
healthy women. J Obstet Gynaecol Can. 2016;38(9):843-865.
18.Stewart D, Benitz W; Committee on Fetus and Newborn. Umbilical
cord care in the newborn infant. Pediatrics. 2016;138(3):e20162149
19.Painter K, Feldman J. Omphalitis. In: StatPearls. Treasure Is-
land, FL: StatPearls Publishing; 2018. https://www.ncbi.nlm.nih.gov/
books/NBK513338/. Accessed January 24, 2019.
20.Ameh EA, Nmadu PT. Major complications of omphalitis in neonates
and infants. Pediatr Surg Int. 2002;18(5-6):413-416.
21.World Health Organization. WHO Recommendations on Post-
natal Care of the Mother and Newborn. Geneva, Switzerland:
Journal of Midwifery & Women’s Health r www.jmwh.org
World Health Organization, 2013. https://apps.who.int/iris/bitstream/
handle/10665/97603/9789241506649_eng.pdf. Accessed January 23,
2019.
22.Imdad A, Bautista RM, Senen KA, Uy ME, Mantaring JB III, Bhutta
ZA. Umbilical cord antiseptics for preventing sepsis and death among
newborns. Cochrane Database Syst Rev. 2013;(5):CD008635.
23.Kirk AP, Yang J, Sim WC, Chia LY, Lau Y. Systematic review of the
effect of topical application of human breast milk on early umbil-
ical cord separation. J Obstet Gynecol Neonatal Nurs. 2019;48(2):
121-130.
24.University of Michigan C.S. Mott Children’s Hospital Department
of Pediatrics. Lotus birth/umbilical non-severance: what to expect.
http://www.med.umich.edu/1libr/Pediatrics/LotusBirthHandout.pdf.
Published June 2016. Accessed May 30, 2019.
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