806843

research-article2018
CPJXXX10.1177/0009922818806843Clinical PediatricsMonroe et al

Article
Clinical Pediatrics

Lotus Birth: A Case Series Report 2019, Vol. 58(1) 88­–94

© The Author(s) 2018
Article reuse guidelines:
on Umbilical Nonseverance sagepub.com/journals-permissions
DOI: 10.1177/0009922818806843
https://doi.org/10.1177/0009922818806843
journals.sagepub.com/home/cpj

Kimberly K. Monroe, MD, MS1,2 , Alexandra Rubin, BS1,2,

Kerry P. Mychaliska, MD1,2, Maria Skoczylas, MD1,2,
and Heather L. Burrows, MD, PhD1,2

Abstract
Lotus birth is the practice of leaving the umbilical cord uncut until separation occurs naturally. Our case series
report describes delivery characteristics, neonatal clinical course, cord and placenta management, maternal reasons
for a lotus birth, and desire for future lotus births. Between April 2014 and January 2017, six lotus births occurred.
Mothers (four of the six) were contacted by phone after giving birth. A chart review was completed on each patient
to evaluate if erythromycin ointment, hepatitis B vaccine, and vitamin K (intramuscular or oral) were administered,
treatment of the placenta, maternal group B streptococcus status, postnatal infant fevers, infant hemoglobin or
hematocrit levels, jaundice requiring phototherapy, and infant readmissions. Three of the six families decided to cut
the cord before hospital discharge. No infections were noted. All contacted mothers would elect for a lotus birth
again (4/6). One hepatitis B vaccine was given; all others declined perinatal immunization.

Keywords
Lotus birth, umbilical nonseverance

Introduction whether there are any health outcomes, positive or nega-

Lotus birth or umbilical nonseverance is the practice of
leaving the umbilical cord uncut so that it and the pla-
centa remain connected to the baby until it detaches
naturally,1 usually up to 10 days after birth.2 The pla-
centa is often wrapped in fabric or a bag3,4 and may be
treated with salts, lavender oil, rosemary, or other herbs
to decrease odors.2,3,5
Very little information has been published regarding
lotus births. In one study, mothers who had or were
planning homebirths, including several who had
elected a lotus birth, were interviewed.4 Mothers
reported viewing the placenta as belonging to the baby,
rather than being a medical by-product; thus, the pla-
centa and umbilical cord were something the baby
should release when he was ready and not before.
Women spoke of the practice in spiritual terms; cleanli-
ness and medical benefits were often secondary con-
cerns. Women in other reports echo this tone,
emphasizing the baby’s control over the placenta and a
spiritual aspect of the experience.3,5
Though these are certainly worthwhile benefits to
mothers and babies, it is also important to consider
tive, associated with lotus birth in order to best treat
patients who request this method of managing the pla-
centa and umbilical cord. No evidence-based research
devoted to clinical outcomes has been published on the
subject. Once it has been delivered, the blood in the pla-
centa is no longer circulating, and the tissue is nonvia-
ble. At this point, the placenta may be at risk of becoming
infected, which could theoretically then spread to the
baby1; however, the likelihood and severity of such an
infection are unknown. The closest comparable data
would be on omphalitis, which is estimated to occur at
1/1000 in high-resource countries.6 There have been no
major documented cases of adverse outcomes related to
lotus births in terms of hemorrhage or infection,2 until
2015 when a case report demonstrated a possible link to
1
The University of Michigan, Ann Arbor, MI, USA
2
C.S. Mott Children’s Hospital, Ann Arbor, MI, USA
Corresponding Author:
Kimberly K. Monroe, Department of Pediatrics, C.S. Mott Children’s
Hospital, 1540 East Medical Center Drive, Ann Arbor, MI 48109,
USA.
Email: monroek@med.umich.edu
Monroe et al 89
neonatal idiopathic hepatitis.7 Some anecdotal reports
have suggested benefits that may result from avoiding
the psychologic trauma of cord severance5; however, no
evidence-based research has been published to support
these claims. In 2015, the American Heart Association
and the American Academy of Pediatrics revised the
neonatal resuscitation guidelines to include the recom-
mendation of delaying cord clamping for 30 to 60 sec-
onds in vigorous term and preterm newborns. For term
infants, the benefits of this delay include increased
hemoglobin levels at birth and improved iron stores for
several months after birth, which may favorably affect
infant development. For preterm infants, delayed
clamping may improve transitional circulation and help
increase red blood cell volume. However, as delayed
cord clamping could lead to a slight increase in the
number of cases of jaundice requiring phototherapy in
term infants, the adoption of mechanisms to monitor
and treat neonatal jaundice is recommended.8,9
To our knowledge, no research exists on the practice,
consequences, or benefits of a lotus birth. Due to this
lack of literature, newborn providers may be at a loss
when counseling mothers who elect to have a lotus birth.
The purpose of this descriptive study is to better under-
stand patients’ experiences and outcomes with lotus
births. This information may be used to develop hospital
policies regarding the practice, as no current standard
guideline has been established.
Methods
This institutional review board–approved study is both a
retrospective and prospective chart review of lotus births
at the University of Michigan C.S. Mott Children’s
Hospital in Ann Arbor. A retrospective chart review was
conducted on lotus births that occurred at C.S. Mott
Children’s Hospital from April 2014 to January 2017.
After July 2016 and through February 2017, the research
team was notified of a lotus birth via email, phone, text
page, or verbal notification either while the mother was
in labor or once the baby was delivered. Hospital faculty
on the newborn delivery unit were notified via handouts
and email to contact the study team when a lotus birth
occurred. All mothers were mailed a handout explaining
the study, including a consent form via US Mail. There
was no face-to-face recruitment.
Mothers were contacted by phone at least 1 month
after giving birth. The consent handout was reviewed
with the mother at this time. After obtaining appropriate
consent, mothers were surveyed about their manage-
ment of the placenta and umbilical cord, the day the cord
separated, their desire for a future lotus birth, and reason
1. What day of life did your baby’s umbilical cord fall off?
2. Did your baby have an infection at or near the umbilical
cord attachment site?
a.  If yes, was your baby hospitalized or managed
outpatient?
b.  If hospitalized, what hospital?
3. Did your baby have a granuloma?
a.  If yes, was your baby hospitalized or managed
outpatient?
b.  If hospitalized, what hospital?
4. How did you treat the placenta? For example, did you use
oils or salts?
5. What is the birth order of this baby?
6. Would you plan for a lotus birth again?
Figure 1.  Phone survey questions.
for desiring the current lotus birth (Figure 1). In addi-
tion, a review of the infant’s chart was conducted to
collect data on other birth-related care. We recorded
available information on gestational age, birth order,
delivery method, mother’s group B streptococcus status,
administration of erythromycin eye ointment, hepatitis
B vaccination, vitamin K administration (intramuscular
[IM] or oral), infant hemoglobin or hematocrit levels,
blood culture (if drawn), postnatal newborn fevers,
infection at umbilical site, granuloma development,
hyperbilirubinemia requiring phototherapy, transcutane-
ous bilirubin and total serum bilirubin in relation to hour
of life and light level, mother’s blood type and baby’s (if
known), treatment of the placenta, and infant readmis-
sions. Vaccination records were obtained through the
Michigan Care Improvement Registry (MCIR)10 to eval-
uate for further vaccinations administered in the outpa-
tient setting.
If we were unable to contact a mother via telephone,
we used only the data available from the baby’s chart.
All data obtained from phone interviews and chart
review were recorded in Microsoft Excel. In addition to
collecting data on lotus births occurring at our institu-
tion during the study period, our team also developed a
protocol for the management of lotus births and plain
language patient education materials for families. The
protocol was created using the available lotus birth
literature.1-5,9,11-15 The consensus protocol was reviewed
by experienced pediatricians who practiced in the
newborn nursery and had cared for babies who had
undergone a lotus birth, and nursing staff. It was
reviewed and approved by the committee who over-
sees our newborn nursery and by obstetricians and
nurse-midwives. See Figure 2 (available in the online
version of the article). A patient handout was created
90 Clinical Pediatrics 58(1)
and reviewed by our patient education librarian to
ensure that it met plain l­ anguage guidelines. This hand-
out is publically a­ vailable on the University of Michigan
patient education ­clearinghouse at http://pteducation.
med.umich.edu/. See Figure 3 (available in the online
version of the article).
Results
Four lotus births were identified as occurring at our
institution between April 2014 and June 2016. An addi-
tional two lotus births occurred between July 2016 and
January 2017 (see Table 1 and pictures). One infant was
delivered by unplanned cesarean section, one by vagi-
nal water birth, and the rest by non-water vaginal deliv-
ery. Only one family consented to administration of
hepatitis B vaccine (HBV) in the newborn nursery; the
other five families declined immunizations in the hospi-
tal. Vaccination records were able to be obtained
through MCIR on five of the six patients. Three showed
no immunizations ever being given, one patient received
only two polio vaccines, and the fifth showed a partially
vaccinated record. Erythromycin eye ointment was
administered 50% (3/6) of the time. Vitamin K supple-
mentation was given to 66.7% (4/6) patients with two
receiving IM vitamin K and two receiving PO (per os)
vitamin K. The hepatitis B vaccination rate in the lotus
birth group was 16.7% (1/6; 95% confidence interval of
[0-0.58]). Three of the families decided to cut the cord
before they left the hospital. No infections were noted.
Two patients received phototherapy. One received pho-
totherapy in the hospital for six hours and was cau-
tiously categorized as having a higher neurotoxicity
risk due to having a sibling with jaundice and being a
lotus birth. The patient otherwise had low neurotoxicity
risk and was 0.7 mg/dL below the medium-risk light
level when started on phototherapy. The other patient
was treated with home phototherapy via a bili-blanket
on day of life four. She was 0.4 mg/dL below the
medium-risk light level, but otherwise had low neuro-
toxicity risk. We were able to contact four of the six
mothers for the telephone interview. All four of these
mothers indicated that they would elect for a lotus birth
with a future delivery.
Discussion
This is a case series report on umbilical nonseverance or
lotus birth. This birth practice is generally not seen in
typical obstetric care, and pediatricians may not be famil-
iar with management of this situation, which leads to
inconsistent messaging to families and care teams. We
had six cases over the course of 33 months in an institu-
tion with approximately 4500 deliveries/year. Although
uncommon, it is important for medical providers to be
aware of this birth practice and its potential risks. As no
evidence-based research has been done on this topic our
study provides some insight into this practice.
Given the rarity of the request for a lotus birth deliv-
ery, medical providers may not have ready information
to use while providing care. We have found it helpful to
have patient education materials, which includes signs
and symptoms of infection as well as a protocol for med-
ical providers to reference. Medical providers should
aim to provide patient-centered care and accommodate
family desires around the delivery experience when it is
safe to do so. Unfortunately, rates of acceptance of stan-
dard, evidence-based newborn care were lower in this
patient population than on our typical newborn service,
with lower rates of HBV (16.7% vs 86.4%), erythromy-
cin eye ointment (50% vs 94.1%), and IM vitamin K
administration (33.3% vs 97.7%), suggesting a need for
focused communication around risk for families elect-
ing a lotus birth.
This study had some limitations. Our newborn nurs-
ery data on HBV vaccination rates, erythromycin and
IM vitamin K administration were obtained from
November 2015 to November 2016, while our study
dates were from April 2014 to January 2017. MCIR
records do not reflect vaccinations given in other states
unless entered by a medical provider. Therefore, it is
unknown if any patient(s) obtained vaccinations in
another state since birth.
Conclusion
As lotus births are rare occurrences with minimal aca-
demic literature available on the topic, it is important to
continue to gather case reports that will further inform
providers who care for infants in the newborn setting.
This will ultimately lead to better patient-centered care
for families electing this practice. In our lotus birth six-
patient case series, no infections were seen and the
majority of mothers expressed an interest in future lotus
births. Because these families may have an increased
rate of declining standard newborn care practices, care-
ful communication strategies should be developed for
discussing known risks for newborns.
 Table 1.  Patient Characteristics.

Patient 1 2 3 4 5 (Pictures) 6
Delivery characteristics
  Gestational age 41 5/7 39 1/7 40 1/7 39 5/7 38 0/7 40 1/7
  Birth order 3 1 3 5 1 4
  Delivery method Vaginal C-section Vaginal Vaginal Vaginal Vaginal tub birth
  GBS status Positive with adequate Unknown with Negative Positive with adequate IAP Negative Unknown—inadequate
IAP adequate IAP IAP
Neonatal clinical course
  Erythromycin ointment Declined Declined Declined Given Given Given
  Hepatitis B vaccine Declined Declined Declined Given Declined Declined
  Vitamin K Given (IM) Given (PO) Declined Given (IM) Given (PO) Declined
 Hemoglobin/hematocrit N/A N/A N/A 16.5/46.3 at 37 hoursa 16.7/49.7 at DOL 20 N/A
(if drawn)
  Blood culture (if drawn) N/A N/A N/A N/A N/A N/A
  Febrile during hospital No No No No No No
stay
  Infection at umbilical No No No—per EMR, No No Unknown—no follow-
site unable to up available by EMR
confirm with or parent
parent
 Granuloma No No No—per EMR, No No Unknown—no follow-
development unable to up available by EMR
confirm with or parent
parent
 Hyperbilirubinemia No (serum bilirubin never No (serum bilirubin No (serum Yes (overhead lights and a Yes (Tcb 4.5 at 18 No (serum bilirubin
requiring phototherapy ordered, Tcb 2.6 at 17 never ordered, Tcb bilirubin never bili-blanket for 6 hours. HOL. TSB 15.7 at never ordered, Tcb
HOL) 8.8 at   ~50 HOL) ordered, Tcb Discharged on a bili- 81 HOL [LRLL 18.6, 5.6 at 18 HOL)
4.3 at 22 HOL) blanket. TSB 8.5 at 20 HOL MRLL 16.1], put on
[LRLL 10.8, MRLL 9.2], bili-blanket in ED
started phototherapy and after discharge from
9.0 at 30 HOL [LRLL 12.7] birth hospitalization)
when discontinued)
  Mother’s blood type A+, DAT− O+, DAT− O+, DAT− B+, DAT−; B+, DAT− A+, DAT−; A+, O+, DAT−; unknown
and baby’s blood type DAT−
(if known)

(continued)

91
92
Table 1. (continued)

Patient 1 2 3 4 5 (Pictures) 6
Cord/placenta management
  DOL for cord N/A N/A 7 10 5—assisted by parent N/A
separation
  DOL for cutting cord/ 2—parents decided to 3—parents decided N/A N/A N/A 2—parents did not feel
reason have the umbilical cord to cut the cord it was convenient
cut for safety reasons “because it was dried to take the placenta
up” home
  Management of placenta Washed and patted dry Coated with a mixture Wrapped in a Coated with a mixture of Cleaned Kept in a small
Placed in a strainer inside of salts, dried diaper and oil, salt, lavender, hibiscus, Coated with a container at
of a bowl lavender, and other swaddled in a rosemary, bay leaves, and mixture of herbs— bedside—per EMR
Wrapped in cloth herbs that were blanket—per anise seeds rosemary, lavender,
with Himalayan salt, obtained from their EMR and Himalayan salt
dried lavender, dried Doula Wrapped in a silky
rosemary scarf and kept in
Changed the dressing a lunch pail at the
periodically for the first same level as the
12 to 24 hours baby
  Maternal desire for a Yes Yes Unknown Yes Yes Unknown
lotus birth for future
children
  Maternal reason for “Wanted the blood from Unknown Unknown It is a “DNA download” Unknown Unknown
desiring a lotus birth the placenta to go to the “It helps the babies develop
baby” better—walk at 8.5
“The placenta is like a months and talk earlier”
twin to the baby and Lotus births were in her
nurtures him” family for years but
“Cutting it is traumatic for stopped during slavery
the baby”

Abbreviations: C-section, cesarean section; GBS, group B streptococcus; IAP, intrapartum antimicrobial prophylaxis; IM, intramuscular; PO, per os; NA, not applicable, DOL, day of life; EMR,
electronic medical record; Tcb, transcutaneous bilirubin; HOL, hour of life; TSB, total serum bilirubin; LRLL, low-risk light level; MRLL, medium-risk light level; ED, emergency department; DAT,
direct antiglobulin test.
a
Rounded up to nearest hour.
Monroe et al 93

Acknowledgments
The authors would like to thank Joanne Bailey, CNM, Carrie
Bell, MD, Anita Hernandez, MD, Michael Levy, MD, and
Linda Gobeski, RN.

Author Contributions
KKM assisted with study design and concept, creation of a
data collection plan, chart review, retrieval of data and analy-
sis, wrote the first version of the manuscript and executed all
manuscript revisions and approved the final manuscript. AR
assisted with study concept and design, data retrieval, per-
formed edits and approved the final manuscript. KPM
assisted with study design and concept, performed edits and
approved the final manuscript. MS assisted with study
design, executed all manuscript revisions and approved the
final manuscript. HLB assisted with study concept and
design, executed all manuscript revisions and approved the
final manuscript.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.

Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.

Supplemental Material
Supplemental material for this article is available online.

ORCID iD
Kimberly Monroe https://orcid.org/0000-0002-0010-3486

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