|ORIGINAL RESEARCH REPORT
|Year : 2017 | Volume
| Issue : 4 | Page : 167-172
Prevalence and predictive factors of birth traumas in neonates presenting to the children emergency center of a tertiary center in Southwest, Nigeria
Babayemi O Osinaike1, Labake O.O Akinseye2, Olubusola R Akiyode2, Chinwe Anyaebunam2, Olusola Kushimo2
1 Department of Accident and Emergency (Paediatrics), Lagos University Teaching Hospital, Idi-Araba, Lagos, Nigeria
2 Department of Paediatrics, Lagos University Teaching Hospital, Idi-Araba, Lagos, Nigeria
|Date of Web Publication||8-Nov-2017|
Babayemi O Osinaike
Department of Accident and Emergency (Paediatrics), Lagos University Teaching Hospital, Idi-Araba, Lagos
Source of Support: None, Conflict of Interest: None
Background: Although the majority of birth injuries are minor and often unreported, occasionally birth injuries may be so severe as to be fatal or leave the child with a permanent disability or even death.Objective: This study aimed to document the patterns and predictive factors of birth injuries in neonates presenting at the emergency center of a tertiary hospital in South west, Nigeria. Patients And Methods: This was a cross-sectional study of neonates who presented at the Olikoye Ransome-Kuti Children Emergency Center of the Lagos University Teaching Hospital between October and December 2016. All neonates admitted for treatment at the center for any clinical condition were included in the study after initial review or resuscitation/treatment for their primary complaint, and consent was obtained from their caregivers. The babies were examined by at least a senior resident and any abnormality documented. Any underlining medical conditions such as asphyxia and neonatal sepsis were properly investigated and treated. Statistical analyses were performed by chi-square, student's t-test, using SPSS version 20.0. P ≤ 0.05 was considered statistically significant. Results: A total of 134 neonates were reviewed during the study period with majority, 84 (62.7%), being males. The mean age at presentation was 65.2 ± 89.2 h (median 24 h). Caput succedaneum (22.2%) and subconjunctival hemorrhage (22.2%) were the most frequent injuries observed, while cranial nerve injury the least. One patient had multiple injuries (cranial nerve injury with fractures humerus). Conclusions: Overall prevalence and pattern of birth injuries in neonates presenting at our emergency center was consistent with various studies from other centers. Parity of the mother, significant maternal medical history, duration of labor, mode of delivery, and skill of attending personnel at delivery were significant factors associated with birth injuries
Keywords: Birth trauma, caput, cephalohematoma, neonates, subconjunctival hemorrhage, subgleal hematoma
|How to cite this article:|
Osinaike BO, Akinseye LO, Akiyode OR, Anyaebunam C, Kushimo O. Prevalence and predictive factors of birth traumas in neonates presenting to the children emergency center of a tertiary center in Southwest, Nigeria. J Clin Sci 2017;14:167-72
|How to cite this URL:|
Osinaike BO, Akinseye LO, Akiyode OR, Anyaebunam C, Kushimo O. Prevalence and predictive factors of birth traumas in neonates presenting to the children emergency center of a tertiary center in Southwest, Nigeria. J Clin Sci [serial online] 2017 [cited 2017 Dec 11];14:167-72. Available from: http://www.jcsjournal.org/text.asp?2017/14/4/167/217821
| Introduction|| |
Birth trauma is defined as injury to infant resulting from mechanical forces (such as compression or traction) during the process of birth. Although the majority of birth injuries are minor and often unreported, occasionally birth injuries may be so severe as to be fatal or leave the child with a permanent disability or even death. They may occur because of inappropriate or deficient medical skills and attention, but they also can occur despite skilled and competent obstetric care.
Although various factors ranging from infant-related factors (very low birth weight infant or extreme prematurity, fetal macrosomia, fetal anomalies, twin [particularly the second one]), maternal-related factors (primigravida, maternal pelvic anomalies, poor maternal health, maternal age [very young and old]), and labor-related factors (prolonged or extremely rapid labor, deep transverse arrest of descent of presenting part of fetus, abnormal presentation, use of mid cavity forceps or vacuum extraction, version, and extraction) have been highlighted as predisposing factors, there are no uniform agreements on the role of specific factors. For instance, while some reports suggest that fetal macrosomia and breech delivery predispose to birth trauma, others do not. These disagreements may represent inter-center differences in experience and study methodology.
The improvements in obstetric practice have resulted in a reduced incidence of birth trauma cases, especially in the developed countries; however, it has been estimated that only about 25% of deliveries are supervised by skilled attendants in the developing countries with the resultantly increased incidence of birth trauma. Nearly one-half are potentially avoidable with recognition and proactive management of the risk.
The study was therefore carried out to document the prevalence and contributory factors of birth trauma/injuries in neonates presenting at the Children Emergency Department of a tertiary center in a developing country. It is hoped that findings from the study will contribute to the attempt at identifying these risk factors with the view to developing appropriate protocols for the prevention of birth injuries where these risks exist.
| Methodology|| |
The study was a prospective observational study carried out over a 3 months period in the Children Emergency Center of the Lagos University Teaching Hospital. All neonates admitted for treatment at the center for any clinical condition were included in the study after initial review or resuscitation/treatment for their primary complaint once consent was obtained from their caregivers. Biosocial/demographic details about neonate and mother were obtained and filled in a questionnaire. The babies were examined by at least a senior resident and any abnormality documented. Any underlining medical conditions such as asphyxia and neonatal sepsis were properly investigated and treated. Parents were informed of any birth injuries observed and treatment instituted. Follow-up care was set up in appropriate specialist clinic.
Data were entered into the Microsoft Excel spread sheets, and analysis was carried out using Statistical Packages for Social Sciences (IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp). Descriptive statistics such as means, medians, and standard deviations were used to summarize quantitative variables such as children's and mothers' characteristics, while categorical variables were summarized with proportions and percentages. Bivariate analysis such as Chi-square test was also employed to investigate the association between incidence of birth injuries and selected sociodemographic and clinical factors. P <0.05 was considered statistically significant.
| Results|| |
[Table 1] reflects the demographic characteristics of the study population. A total of 134 neonates were reviewed during the study period with majority, i.e. 84 (62.7%), being males. The mean age at presentation was 65.2 ± 89.2 h (median 24 h). Overall mean gestational age (GA) was 37.9 ± 1. 4 weeks; however, those that sustained birth traumas were slightly older (mean GA 37.9 ± 1.5 weeks) compared with those that had no injuries (mean GA 37.7 ± 1.4 weeks), but the difference was not statistically significant (P = 0.34). Overall mean birth weight was 3161.1 ± 775.2 g with children presenting with birth trauma being slightly bigger (mean birth weight 3220 ± 835.3) than children without any evidence of trauma (mean birth weight 3040.9 ± 626.3 g), P = 0.21. Overall mean maternal age was 29.7 ± 5.4 years, while it was 29.6 ± 5.5 years for women whose children had birth trauma and 30.2 ± 5.3 years for those with apparently uninjured newborns (P = 0.53).
As shown in [Table 2], 68 mothers (50.7%) had secondary level of education while primary was the least completed (11.9%). Majority of the mothers (56.7%) had low-risk parity (para 2–4) while high risk (para 0–1 and para 5) was observed in 43.5%. Previous abdominopelvic surgery (7.5%) was the most common medical history in the mothers, while obesity and smoking were the least (1.5%). Majority of the mothers (76.1%) had no documented medical risk factors.
Only 4 (3%) mothers did not attend any antenatal care at all, while majority 58 (43.3%) received their antenatal care in private hospital with four (3%) mothers reporting traditional birth attendants as their source of antenatal care.
The perinatal profile of the patients is reflected in [Table 3]. Most frequent presentation was vertex (92.5%), while shoulder (1.5%) and face (1.5%) were least common. Multiple gestation was reported only in 6 (4.5%) mothers. Seventy mothers (52.2%) reported that they had normal duration of labor while it was prolonged in 19.4%. Elective cesarean section was the least frequent mode of delivery (4.5%) while 52 children (38.8%) were reported to have been asphyxiated at birth.
As shown in [Table 4], ninety neonates (67.2%) presented with documented birth trauma on arrival in the emergency department with caput succedaneum (22.2%) and subconjunctival hemorrhage (22.2%) being the most frequent injuries observed while cranial nerve injury was the least. One patient had multiple injuries (cranial nerve injury with fractures humerus).
[Table 5] depicts the relationship between the neonatal factors and occurrence of birth injuries. There was no significant association between gender, GA, or birth weight of the patient and the occurrence of birth trauma. Pregnancy type and asphyxia did not appear to have any impact on the frequency of birth trauma.
|Table 5: Relationship between neonatal profiles and presence of birth traumas|
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Parity of the mother and presence of a medical history in the mother were observed to have a significant association with the occurrence of birth traumas (P ≤ 0.001 and 0.012, respectively) as shown in [Table 6].
|Table 6: Relationship between maternal profiles and presence of birth traumas|
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Duration of labor, mode of delivery, and grade of personnel present at the delivery were documented to have positive association with the presence of birth injuries (P = 0.025, 0.009, and 0.005 respectively) as documented in [Table 7].
|Table 7: Relationship between perinatal characteristics and presence of birth trauma|
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| Discussion|| |
Majority of the patients involved in our study were males, consistent with the observation of most series. However, gender did not appear to play any role in the development of birth trauma contrary to the reports of Abedzadeh-Kalahroudi et al. and Sauber-Schatz et al., which documented that boys are more prone to birth injuries. Other authors such as Ray et al. have reported a female predisposition in their work.
The range of birth injuries in this study is in keeping with the reports of other studies. Consistent with the reports of other studies,, scalp soft tissue injuries (caput, subgleal hematoma, and cephalohematoma) were most prevalent injuries observed in our cohort. However, fracture of long bones were more frequently seen in our study compared with fractured clavicle at variance with earlier reports from some authors ,, but consistent with findings of Hameed and Izzet. The skill of the attending care provider at delivery may largely have impacted on this as most deliveries had inexperienced personnel or personnel of unknown skill level in attendance during the labor.
Unlike the report of other series, GA at delivery and birth weight did not have any impact on the incidence of injuries in the neonates reviewed. Various authors have documented extreme birth weight as a putative risk, with higher birth weight (above 4000 g) being strongly associated with birth injuries.
While maternal age did not impact the incidence of birth injuries, multiparity in the mother did appear to protect our patients from injuries keeping with the opinion of some authors that nulliparity in the mother is an increased risk factor for the occurrence of birth trauma. The reasons adduced for this increased incidence among the nulliparous include their inexperience, pelvic contraction, and some form of bony and soft tissue dystocia.,
Maternal medical/social history was observed to have a significant impact on the incidence of birth injuries with putative risk factors such as smoking, abdominopelvic surgeries, and diabetes mellitus (DM) being documented only in mothers whose newborns had birth injuries. This is consistent with the work by Hameed and Izzet  where previous surgeries and history of DM were documented to be significantly more in neonates with birth injuries. In contrast, Ray et al. did not document any association of these putative risk factors with occurrence of birth injuries in 4741 children.
Labor-related factors such as duration of labor, mode of delivery, and skill of attending physician/care provider were found to be univariable predictors for birth trauma in our study. This is consistent with the works of other authors.,, There appear to be divergent views on the protective role of cesarean section on neonatal injuries as some authors have reported different outcomes.,, We observed that incidence of birth injuries appears to be significantly higher in emergency cesarean section compared with vaginal deliveries. The different rate of surgical deliveries in specific centers appears to impact on the outcomes as some authors had significantly higher proportion of babies delivered via cesarean section in their centers, hence the perceived higher incidence in their reports.
The limitation of the study is in the fact that the data reflected the pattern from outborn patients from various medical centers outside the teaching hospital where there is often no defined protocol of care during labor and delivery. A comparative cohort of inborn babies in the teaching hospital may be useful to evaluate the impact of some of these factors. The strength of the study lies in the fact that it was a prospective study.
| Conclusion|| |
Data from developing countries are scare; hence, this study adds to the needed data on this significant cause of morbidity and mortality in resource limited countries like ours. Furthermore, it highlights the dangers that will be associated with poor management of obviously identified risk factors such as maternal medical history, parity of the mother, mode of delivery, and skill of attending medical personnel that can lead to birth injuries. There is also a need for continuous improvement in case specific monitoring of pregnancies and prompt referral where the level of competence of the managing physician is not appropriate or unknown.
We wish to thank the residents and nursing staff in the Olikoye Ransome-Kuti Children Emergency Center for their cooperation and care of these patients in their most difficult moments at presentation.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]