The parents of a baby boy who died from a common but undetected infection during a homebirth in Dublin three years ago have welcomed new HSE guidelines for testing pregnant women for Group Strep B infection.
The baby, Rob Cashin, was pronounced dead at the Rotunda Hospital in Dublin less than an hour after being partially delivered in a birthing pool at his family home in Holywell Gardens, Swords, Co Dublin on August 27th, 2020.
The third and final day of an inquest into his death at Dublin District Coroner’s Court heard postmortem results showed he was delivered stillborn as a result of bronchial pneumonia which was due to Group Strep B infection.
The coroner, Clare Keane, was informed that the HSE had suspended allowing pregnant women to deliver in a birthing pool as a result of the case.
The baby’s parents, Paula and Colm Cashin, who have two other children, said they had never heard of Group Strep B infection before Rob’s death but now realised it was a common infection in pregnant women which killed around 5 per cent of all babies who contract it from their mother.
New guidelines
Although there was no routine testing of pregnant women for Group Strep B at the time of their baby’s death, they welcomed the fact that the HSE was in the process of implementing new guidelines for when testing should be carried out so that affected women could be treated with antibiotics.
The couple said their world was shattered when their second child had died after a happy and healthy pregnancy and short labour at home “without any warning".
“While we are heartbroken that the infection was not detected in our case, we are so incredibly grateful to hear that new guidelines are being introduced by the HSE and maternity hospitals….to fight against this silent killer by providing screening and treatment to a wider net of women and babies at risk,” they remarked.
They added: “We sincerely hope that the new guidelines and practices introduced will prevent other families from experiencing the indescribable pain and heartache that we have experienced.”
A pathologist, Noel McEntagart, said the infection would have made it difficult for the baby to take its first breath, and he believed he would have died between the onset of labour and delivery.
Birthing pool
The inquest had earlier heard evidence from midwives that Ms Cashin had been taken out of the birthing pool after the baby’s head had been delivered underwater because of a slight difficulty in delivering its shoulder.
However, Dr McEntagart said it was unlikely to have been a contributory factor in his death.
He also said it was unlikely that the Group Strep B infection had been contracted while in the birthing pool, while there was also no evidence that the partial delivery of the baby underwater had resulted in any lack of oxygen.
In response to questions from the coroner, Dr McEntagart said it was impossible to say when the mother and baby became infected with Group Strep B, but he did not think the infection was “a longstanding feature".
The inquest heard that new HSE guidelines are being introduced which allow individual hospitals to decide what type of screening should be used to test for Group Strep B.
Homebirth
Cliona Murphy, the clinical director of the HSE’s National Women and Infants Health Programme which oversees the HSE’s homebirth service, said hospitals should conduct either risk-based screening, checks on women due for induction or universal screening of all women.
However, she said women who tested positive for Group Strep B would not be considered eligible for homebirths.
Dr Murphy, a consultant obstetrician and gynaecologist, said deliveries in birthing pools had been suspended as a result of the death of baby Rob on “prudent” grounds.
She told the coroner that homebirths only represent 0.4 per cent of all births in the Republic.
However, she said they had grown in popularity in recent years, particularly during the Covid-19 pandemic.
The inquest heard that between 2018 and 2020, 489 women out of 848 who had registered for a homebirth had gone on to give birth at home.
However, no figures are available for how many births were underwater.
Dr Murphy said approximately one in five women who give birth at home need to be transferred to hospital for various reasons.
Recommendations
She also informed the coroner that the latest recommendation stipulated that women availing of homebirths should be able to reach a hospital within 30 minutes under “blue lights” driving which she said applied to 83 per cent of all such patients.
Dr Murphy said new guidelines on when women should be induced for labour are due to be announced in September.
The consultant said she expected that they would allow pregnant women the option of earlier inductions.
The inquest had earlier heard Ms Cashin express concern that there appeared to be different policies between women attending the Rotunda and those opting for homebirths on when they could be induced.
A consultant obstetrician at the Coombe Hospital in Dublin and expert on labour and birth underwater, Deirdre Murphy, said the chance of a baby being infected with Group Strep B if its mother had been given antibiotics was incredibly low as the treatment is usually “very effective".
Prof Murphy noted that up to 15 per cent of pregnant women have the infection.
However, she also stressed that even in countries where there is a universal screening programme for Group Strep B in pregnant women, like the US, that up to 10 per cent of tests were false negatives.
“It is not an absolutely clear-cut thing,” she remarked.
Prof Murphy observed that there was a heightened awareness of the risk of infection in labour and births underwater because they occurred in a warm water environment which had the potential to allow bacteria to multiply.
She pointed out that pregnant women in Ireland who are taking antibiotics to treat an infection are not allowed to use a birthing pool, unlike in the UK.
However, she said the incidence of Group Strep B infection coming from the actual water used in a birthing pool was “vanishingly rare".
Recording a narrative verdict, the coroner said baby Rob had died at the end of an uncomplicated pregnancy to his mother who was considered a low-risk case for a homebirth and from complications that were not predictable to midwives.
Offering her condolences to the couple, Dr Keane said she endorsed the current reviews of guidelines for testing for Group Strep B infection and on when labour should be induced.
The coroner expressed hope that revised guidelines would specify criteria in relation to suitability for homebirths.
