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Charusheela Warke*, Sushma Malik**, Manish Chokhandre***, Ashwin Saboo****

*Associate Professor,** Professor, ***Resident, **** Assistant Professor Division of Neonatology, Dept. of Paediatrics, BYL Nair Ch. Hospital and TN Medical College, Mumbai-400 008.

Birth Injuries - A Review of Incidence, Perinatal Risk Factors and Outcome

AbstractIntroduction : Birth injuries are avoidable or unavoidable forms of birth trauma which occur during the process of labour and delivery. Incidence of birth injuries is 6-8 per 1000 live births. Predisposing factors were instrumentation (forceps/vacuum), macrosomia, difficult labour, shoulder dystocia, maternal pelvic anomalies. Current study focuses on determination of incidence, risk factor and outcome of mechanical birth injuries in all live born neonates admitted at our tertiary level NICU.Methods : In this retrospective study, medical records of all neonates in our NICU and postnatal ward in our hospital during year January 2009 to December 2010 were reviewed. Data were analysed to calculate rates for all birth trauma and specific types of birth injuries. Parameters including type of delivery, birth weight, gender, known risk factors in mother and type of birth injuries were recorded.Setting : Level III NICU in a tertiary care referral centre.Results : Incidence of birth trauma (19 cases amongst 5837 live born) in our institute was found to be 3.26 per 1000 live births in 2 years study period. Medical records of all newborns with birth injuries were analysed. Most common birth injury being bleeds (51.16%) of which cephal haematoma (38.7%) was commonest. Higher incidence being noticed in vaginal deliveries (83.9 %) as compared to caesarean deliveries (16.1%) and 25.8% birth injury cases were associated with instrumentation (forceps and vacuum). The predisposing factors were difficult labour (41.9%), difficult breech extraction, macrosomia, shoulder dystocia, maternal pelvic anomalies, 25.8% were associated with instrumentation (forceps/vacuum) and no risk factor was found in 32.3%.Conclusion : Regular follow up during ANC period, early identification of risk factor for difficult delivery, stoppage and avoidance of traumatising manoeuvres and instrumental deliveries and early intervention in form of LSCS when indicated are key factors in reducing traumatic birth injuries.

Introductionirth injury is damage sustained to the Bbaby during the birth process,

usually during transit through birth 1,2canal. Birth related trauma was

suggested to be mostly due to difficult vaginal delivery especially with the shoulder in the vertex presentation or extended arms in a breech delivery, macrosomia, shoulder dystocia, and use of instruments like forceps or vacuum during delivery. The average incidence of birth injuries is 6-8 cases per 1000 live

Original/Research Articles

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1-3births. Birth injuries in newborns may range from minor soft tissue injuries at birth, long bone fractures and broken

4-5collar bone, bleeds (cephalhaematoma, subgaleal bleed, and intracranial bleed)

2,6and peripheral nerve injuries. Our study was done to determine incidence, risk factors and outcome of birth injuries.

Material and MethodsThis was a retrospective study which

included all preterm, full term live born delivered (inborn babies) at or admitted at our tertiary care centre NICU and

stpostnatal ward, from 1 January 2009 to st31 December 2010 and data of 5837

inborn newborn were analysed. The neonates who were referred from other hospitals (outborns) to our tertiary care centre were also included in our study; however these babies were not included in the calculation of the incidence and this was calculated per 1000 births.

The newborns were examined after birth by a paediatrician, and relevant specialty consultations were taken. In cases of fracture, diagnosis was confirmed by radiography of affected part, pathological fractures being excluded. We reviewed the medical files with respect to parameters like type of delivery (vaginal or caesarean section), presentation (vertex or Breech), dystocia, difficult birth, instrumentation, maturity, birth weight, relevant investigations and outcome was recorded. Detailed maternal history noted and thorough examination of the newborn was done.

SettingLevel III NICU in a tertiary care referral

centre.

Results During the study, there were 5837 live

births at our centre and among these 19 infants were delivered with birth injuries, giving an incidence of 3.26/1000 live births and 12 cases were referred from peripheral hospitals

We encountered various birth injuries in our NICU, ranging from cephal haematomas -12, followed by 4 cases of sub galeal haematomas, 3 cases of clavicular fractures, 3 cases of facial palsies, 3 cases of superficial injuries on face, 2 cases of Erb's palsies, 1 case each of fracture humerus, femur, bilateral humerus with clavicle, and a case of superficial injury to eye.

Table-1-Demographic Distribution, Type of Delivery and Outcome

No. 17 14 6 25 26 5 28 3

Percentage 54 46 19.4 80.6 83.9 16.1 90.4 9.6(%)

Para-meters

Gender Birth Weight

Type Of Delivery

Outcome

M F 2kg Vaginal LSCS Disch-arged

Ex-pired

No. Percentage Type Of Injury

Table-2 Percentage distribution of type of injury

Fractures 6 19.3

Clavicular -1 3 9.6

Humerus 1 3.2

Bilat Humerus With Clavicle-1 1 3.2

Femur-1 1 3.2

Neurological Injuries 5 16.12

Facial Palsy-2 3 9.67

Erb's Palsy-1 2 6.4

Bleeds 16 51.6

Cephal- Haematoma-4 12 38.7

Subgaleal -Haematoma-2 4 12.9

Superficial Injuries 4 12.8

Marks On Face 3 9.6

Injury To Eye 1 3.2

Total 31

204 Bombay Hospital Journal, Vol. 54, No. 2, 2012

M o s t c o m m o n b i r t h i n j u r y encountered was bleeds (51.16%) of which cephalhaematoma (38.7%) was the commonest followed by subgaleal bleed (12.9%) and clavicular fractures (9.6%). Birth injuries, in our series, were more frequent in vaginal deliveries (26/31) i.e. (83.9 %) as compared to caesarean deliveries (5/31) i.e. (16.1%) and 25.8% of all our birth injury cases were associated with instrumental deliveries (forceps and vacuum). Amongst the five patients

Photo-1: Right sided facial nerve palsy

Photo-2: Bilateral fracture humerus

Photo-3: Large subgaleal haematoma

Photo-4 Cephalhaematoma in a forceps delivery

Photo -5-Forceps mark on forehead

Bombay Hospital Journal, Vol. 54, No. 2, 2012 205

delivered by LSCS, four cases were done after vaginal deliveries had failed to deliver the baby, thereby resulting in birth injury. Common predisposing factors included prolonged labour (41.9%), instrumental deliveries (25.8%), difficult breech extraction, macrosomia, shoulder dystocia and maternal pelvic anomalies. No risk factor was found in 32.3% of all birth trauma cases.

In our cohort, 3 babies died due to secondary causes like sepsis and severe birth asphyxia. Among these three babies, one LBW newborn was a case of birth asphyxia with multiple limb fractures and sepsis, another neonate with a large subgaleal haematoma had severe birth asphyxia and hypovolaemic shock and the third case was an FT home delivery with facial palsy with hyper echoic foci in bilateral basal ganglia and sepsis.

DiscussionBirth injuries are defined by the

National Vital Statistics report as "an impairment of the infant's body function or structure due to adverse influences that occurred at birth." It can occur antenatally, intrapartum or during

7resuscitation. Different studies have reported varying incidence of birth trauma ranging from 0.2 to 2 per 1000 births as

7per Hankins et al. in 2006 to as high as 37 3per 1000 births. Our study reported birth

trauma incidence of 3.26 per 1000 births without any risk factors in 32.2% of cases suggesting that even during an uncomplicated natural vaginal delivery the neonate is exposed to several forces as it passes through the birth canal that can

2,8cause birth trauma.

Epidemiological factors The incidence of birth trauma has

reportedly decreased over time because of improvements in obstetric care and prenatal diagnosis however, it still occurs even in the presence of highly skilled

3obstetric and neonatal care. Studies have also documented a marked racial variation in the occurrence of birth injuries; namely

3in the Asian or Pacific Islander race. All of our cases belonged to the lower middle class Asian population. Besides racial differences in incidence there is also male sex preponderance noted in birth injuries. Possible environmental factors include geographic location, commoner in urban or wealthy areas and being born in Western, urban and/or teaching hospital. The above mentioned factors along with a co-diagnosis of high birth weight, instrument delivery, malpresentation and other complications during labour and delivery are significant univariable

3predictors for birth trauma.

Aetiopathogenesis and Risk FactorsRisk factors that make a baby more

vulnerable to birth trauma include large-for-date infants, particularly infants who weigh more than 4000 g, instrumental deliveries, especially forceps (mid cavity), or vacuum, vaginal breech delivery, precipitous labour, various obstetric version manoeuvres and abnormal or

Table-3: Major Risk Factors Involved in Birth Injuries

Risk Factors No. Percentage (%)

Instrumentation 8 25.8

Forceps 6 19.3

Vacuum 2 6.4

Difficult Labour 13 41.9

None 10 32.2

206 Bombay Hospital Journal, Vol. 54, No. 2, 2012

8-10excessive traction during delivery. Prolonged or too short labour, maternal pelvic anomalies and skills of obstetrician may also contribute in occurrence of these injuries.

Common risk factors found in our series were instrumentation, like application of forceps or vacuum (25.8%) and difficult labour (difficult breech extraction, shoulder dystocia, prolonged labour/CPD, macrosomia) in (41.9%) of all our cases. Birth injuries, in our series, were more frequent in vaginal deliveries (26/31) as compared to caesarean deliveries (5/31) which correlated with

4that observed by Mosavat et al and 25.8% of all our birth injury cases were associated with instrumental deliveries (forceps and vacuum). Also we observed a higher incidence of injuries with newborns weighing > 2 kg as found by Benjamin et al

9in 1993. We also had a male preponderance as described by Erin et al in 2003 with male: female ratio being 17:14.

Clinical presentation, Complications, Diagnosis and Management

The spectrum of the common types of birth injuries ranges from CNS trauma, extra cranial or intracranial haematoma, soft tissue injuries, nerve palsies, fractures of limb bones and haematomas

2in solid abdominal organs. Complications of birth injuries can be of two types, acute, with haematoma formation, anaemia, shock, sepsis, jaundice spinal shock, paralysis, and chronic like deformity, cont rac tures , l oss o f funct ion , hydrocephalus and delayed milestones etc. These usually occur if the nature of the

injuries is extensive with massive blood loss, septicaemia or damage to vital organs. The most commonly found extracranial bleeds which disappear over weeks to months but can also cause jaundice and anaemia in the neonate if

11size increases, were cephalhaematomas (38.7%) where blood accumulates below the periosteum, with increase in size after birth, followed by subgaleal bleed (12.9%), i . e . b l e ed ing unde r the Ga l ea Aponeurotica, which is a boggy swelling

11leading to shock, if massive. Subconjunctival haemorrhage, which

is caused by rupture of small blood 7vessels, is benign generally resolving

without intervention or complication after one to two weeks. Oedema and ecchymosis often follow soft-tissue injuries, particularly of the periorbital and facial tissues in face presentations and of the scrotum or labia during breech deliveries. Among the long bone fractures, fracture clavicle, reported in 0.2% to 10% of

5deliveries, is the most common site 1followed by fracture humerus. It is a

greenstick fracture, with callus formation in one week, rapid healing with

5remodelling uneventfully, and is treated by making a sling by pinning the shirt sleeve of the involved side to the opposite side of the infant's shirt.

We had three cases of clavicular fractures (9.6 %), (two males and one female), all more than 2 kg in birth weight, all born of vaginal delivery, with one case having breech presentation and one case requiring forceps instrumentation. All other cases of fractures can be diagnosed clinically by deformity, swelling, crepitus,

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pseudo-paralysis, loss of contiguity, 1tenderness, and confirmed radiologically

or by u l t rasonography showing interruption of the hyperechogenic zone of the bone, axial deviation, visible periosteal

5lesions and haematomas. Fractures of femur and humerus which are a rare occurrence, can result in traumatic lacerations of the major blood vessels and adjoining tissues leading to gangrene, haematoma formation and shock with sepsis, incidence being 0.13 per 1000 live

1birth according to Morris et al. Rarely, nerve injuries occur,

consisting of facial nerve palsy (9.67% in our study) resulting from pressure on the facial nerve due to forceps application causing facial asymmetry and weakness of

11the muscles on one side of the face, usually resolves by 2 to 3 months of age, followed by Brachial plexus injuries due to shoulder dystocia, breech extraction, or hyper abduction of the neck in cephalic

11presentations. Commoner ones include Erb's palsy (6.45% in our study), an upper

thbrachial plexus injury involving the 5 and th6 cervical nerves, and Klumpke's palsy, a

th thlower plexus injury involving the 7 and 8 cervical nerves, which are treated by immobilisation and later passive range-of-motion exercises of the arm to prevent

11contractures. MRI may be done to determine the extent of injury to the nerve

11plexus, roots, and cervical spinal cord. Infants should receive vitamin K, platelets or FFP, blood transfusion, appropriate fluid management and ionotropes for massive bleeds and shock and appropriate antibiotics for septicaemia.

Prevention The occurrence of major birth trauma

requires careful study and preventive efforts to better promote newborn health as it contributes to increased neonatal

9morbidity and mortality. Regular audit of delivery practices, greater care in excluding cephalopelvic disproportion and judicious use of forceps and vacuum extraction are recommended to reduce the

8morbidity. Primigravida mothers should be evaluated carefully during ANC follow-

12up. Early identification of obstetric factors and stoppage of traumatising manoeuvres would reduce the incidence

8and severity of this disability. A newborn who has sustained birth injury is a great concern for the parents, obstetrician and paediatrician. And such event may initiate litigation and legal action against the

2doctor and requires proper counselling and communication by the hospital staff.

Conclusions Our incidence of birth injuries at our

hospital (3.26/1000 live births) was much lower than the average. Bleeds was the commonest injury, followed by fractures and neuropraxia. Frequency of injuries was much more in vaginal and instrumental deliveries. In our series risk

rdfactors were encountered in 2/3 of rdsubjects and 1/3 had no risk factors.

Carry home messages1. Identification of the high risk mothers,

the foetus, and also the appropriate labour management may be effective to reduce the rate of birth injuries.

2. Early and regular antenatal visits to identify high risk mothers.

208 Bombay Hospital Journal, Vol. 54, No. 2, 2012

3. In difficult and prolonged labour and in risk associated labour, caesarean section may be selected as an alternative safe method for delivery to avoid birth injuries.

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Intensive Glucose Lowering Treatment in Type 2 DiabetesIf found that a 0.9% lowering of glycated haemoglobin (HbA ) 7.5% v 6.6%) was associated with a 1c17% reduction in non-fatal myocardial infarctions, 15% reduction in coronary events, and a trend towards lower stroke risk with no statistical evidence of heterogeneity. The meta-analysis is consistent with earlier evidence that the cardiovascular benefit of intensive glucose lowering seems to be modest at best, and that glucose lowering is probably less efficacious and more difficult to achieve than lipid lowering and blood pressure control. A combined approach that targets glucose lowering, lipid lowering, and blood pressure control seems to be most beneficial and available data also suggest a long lasting beneficial effect on diabetes related clinical events many years after an intensive regimen. The authors rightfully say that an improvement in surrogate markers (such as HbA ) is not conclusive evidence of clinical benefit.1cBoussageon and colleagues' study provides large scale quantification of the effect of intensive glucose lowering on microvascular disease. Intensive glucose lowering reduced new or worsening microalbuminuria, with a trend towards a reduction in new or worsening retinopathy, but it had little effect on other end points.

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