|Year : 2016 | Volume
| Issue : 2 | Page : 91-95
Prospective study of neonatal birth trauma: Indian perspective
Somosri Ray1, Rakesh Mondal2, Moumita Samanta2, Avijit Hazra3, Tapas Kumar Sabui2, Arijit Debnath4, Kaushani Chatterjee2, Debadatta Mukhopadhayay2, Archan Sil2
1 Department of Neonatology, Medical College, Kolkata, West Bengal, India
2 Department of Pediatric Medicine, Medical College, Kolkata, West Bengal, India
3 Department of Pharmacology, Institute of Postgraduate Medical Education and Research, Kolkata, West Bengal, India
4 Department of Gynecology and Obstetrics, Hindu Rao Hospital, New Delhi, India
|Date of Web Publication||8-Apr-2016|
Department of Pediatric Medicine, Medical College Kolkata, 88 College Street, Kolkata - 700 073, West Bengal
Source of Support: None, Conflict of Interest: None
Background: Birth injuries are mechanical traumas which occur during the process of labor and delivery. The reported incidence varies widely, and various predisposing maternal, neonatal, and labor-related risk factors are documented. However, prospective analysis of epidemiological factors from India is limited. Objective: To delineate the incidence, risk factor, and outcome of birth injuries in our tertiary level teaching and referral hospital. Design: Prospective observational study. Setting: Neonatology Divisions of Department of Pediatric Medicine of our institute. Participants: All inborn babies from singleton pregnancies over an 8 months period. Methods: All newborns were screened for birth trauma after birth. Maternal medical records and labor details were scrutinized. Babies with birth trauma were followed-up for 6 months to assess outcome. Following descriptive analysis, data on risk factors were analyzed in a case-control design. Outcome: Spectrum of birth trauma and its correlation with risk factors. Results: Seventy-three events were recorded from 4741 live births giving an incidence of 15.4/1000 (95% confidence interval 11.9-18.9). Majority were soft tissue injury (0.59%) followed by scalp and skull injury (0.51%). Higher maternal age, shorter height, higher birth weight, instrumental delivery, malpresentations, prolonged labor, obstructed labor, and delivery during risk hours were identified as significant risk factors though the level of risk varied-prolonged labor and instrumental delivery were the strongest. Only two neonatal deaths were attributable to birth trauma. Conclusion: The risk factors for neonatal birth trauma are to be identified and to be addressed for better neonatal outcome.
Keywords: Birth trauma, newborn, risk factor
|How to cite this article:|
Ray S, Mondal R, Samanta M, Hazra A, Sabui TK, Debnath A, Chatterjee K, Mukhopadhayay D, Sil A. Prospective study of neonatal birth trauma: Indian perspective. J Clin Neonatol 2016;5:91-5
|How to cite this URL:|
Ray S, Mondal R, Samanta M, Hazra A, Sabui TK, Debnath A, Chatterjee K, Mukhopadhayay D, Sil A. Prospective study of neonatal birth trauma: Indian perspective. J Clin Neonatol [serial online] 2016 [cited 2021 Apr 12];5:91-5. Available from: https://www.jcnonweb.com/text.asp?2016/5/2/91/179898
| Introduction|| |
Birth trauma or perinatal trauma refers to injury suffered by the newborn during delivery or at any point during entire birth process. , The reported incidence of birth trauma varies widely in Western literature and in reports from developing countries. ,, It may be associated with an increase in both mortality and morbidity. ,,,, The overall incidence of birth injuries has declined with improvements in obstetrical care and prenatal diagnosis. Birth trauma in newborns commonly includes minor soft tissue injuries, fractures of the long bones or clavicle, cephalhematoma, and peripheral nerve injuries. ,,, In literature, different risk factors have been highlighted such as large babies, instrumental deliveries, malpresentations, and labor complications. ,, Study of birth trauma from Indian perspective is scarce. The present study was, therefore, planned to document the incidence and risk factors for birth trauma with the broader goal of generating inputs toward reducing neonatal mortality and morbidity.
| Methods|| |
Prospective observation of 4741 live births in singleton pregnancies was carried out at our Tertiary Care Teaching Maternity Hospital, part of one of the oldest medical colleges in India from March 2014 to October 2014. The catchment area of the hospital includes the municipal limits of the city as well as several adjoining districts. All the live births during the mentioned period were included in the study.
After delivery, the newborn was examined clinically, and anthropometry carried out in the delivery room itself. Information about mother's age, weight, height, body mass index, parity and past obstetric history were noted at the time of delivery, duration of labor, intrapartum complications, time, and mode of delivery were recorded. The prolonged labor is defined when the combined duration of the first and the second stage is more than 18 h, and obstructed labor is one where in spite of good uterine contraction, the progressive descent of the presenting part is arrested due to mechanical obstruction, either due to factors in the fetus or the birth canal or both. Resuscitation details, birth weight, sex of the baby, head circumference, and gestational age were noted. If necessary, data were cross-checked against labor room records. All the newborns with birth trauma were investigated to confirm the diagnosis, and appropriate management offered within the hospital itself. These babies were followed-up until 6 months of age.
Data obtained have been summarized by routine descriptive statistics; 95% confidence intervals (CI) of proportions, based on a binomial distribution, have been presented where deemed relevant. Numerical variables have been compared between subgroups by Student's independent samples t-test if normally distributed, or by Mann-Whitney U-test if skewed. Chi-square test was employed for intergroup comparison of categorical variables. A P < 0.05 has been considered to be statistically significant. To assess significant predictors of birth trauma, numerical and categorical variables that showed a statistically significant difference between the neonates with birth trauma and without trauma on univariate comparison were entered into a single step logistic regression model. Adjusted odds ratios were calculated from this model. Statistica version 6 (Stat Soft Inc., 2001, Tulsa, Oklahoma, USA) and SPSS Statistics 17 (SPSS Inc., 2008: Illinois, Chicago, USA) software were used for statistical analysis.
| Results|| |
During the study period of 8 months, 73 birth injuries were noted among 4741 live births, giving an incidence of 15.4/1000 (95% CI: 11.9-18.9) live births.
[Table 1] depicts the injury site distribution. As is evident from this table, soft tissue injuries and scalp and skull injuries accounted for the majority of birth trauma incidents. Bone, nerve, and eye injuries had nearly similar frequency of between 1 and 2/1000 live births.
|Table 1: Distribution of nature of birth injuries in the study cohort of 4741 live births|
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[Table 2] summarizes the maternal and neonatal demographic and anthropometric profile of the cases with comparison versus other live births where birth injuries did not occur. Mothers of babies with birth injury were on an average 3 years younger and 7 cm shorter than mothers of uninjured babies. Differences in mean gestational age and weight were modest but statistically significant.
|Table 2: Maternal and neonatal parameters compared between live birth cases with and without birth trauma |
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In the study cohort, 31.51% of injured babies were delivered by lower segment cesarean section as against 19.09% of uninjured babies (P = 0.005), and 27.39% of injured babies were born before 37 completed weeks as against 19.62% of their uninjured counterparts (P = 0.098). The proportion of female babies was higher among birth trauma cases. Injured babies were, on average, about 0.5 kg heavier than their uninjured counterparts, and their median head circumference was also 1 cm greater. There were seven babies (9.59%) weighing >3.5 kg at birth among neonatal birth trauma group but none among the other group without it. Incidence of low birth weight (i.e., <2.5 kg) was 11 (15.06%) among birth trauma babies and 2805 (60.09%) among their uninjured counterparts.
[Table 3] summarizes the distribution of other putative risk factors for birth injury among the injured and noninjured cases along with univariate comparisons. As can be seen from [Table 3], putative pregnancy-related risk factors, such as primigravida status, history of abortion, pregnancy-induced hypertension, diabetes, and antepartum hemorrhage did not differ significantly between both the groups with or without neonatal birth trauma. However, the babies with birth injury provided history of stillbirth with significantly greater frequency than other group. On the other hand, labor and delivery-related factors showed substantial differences between two groups, with adverse factors such as instrumental delivery, difficult presentations, prolonged and obstructed labor being more frequent among the birth trauma group, and likely predisposing to it. The incidence of birth trauma was higher during the early morning hours (2:00-8:00 am).
|Table 3: Univariate comparison of putative risk factors for birth trauma between cases with and without birth injuries|
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[Table 4] presents the factors that turned out to be significant upon multivariate (logistic regression) along with adjusted odds ratios as appropriate. The model quality was good with 99.7% of the birth trauma cases being correctly classified. Nagelkerke's R2 = 0.826 indicating that 82.6% of the variability encountered in the model could be accounted for by the predictors tested. Increasing maternal age and weight, higher birth weight, prolonged labor (which is strongly associated with instrumental delivery, both forceps and ventouse), breech presentation, and unfavorable time of delivery (2:00-8:00 am) emerged as the significant risk factors from logistic regression analysis. The initial exploration showed strong collinearity between prolonged labor and instrumental modes of delivery, and therefore, prolonged labor was entered into the final model, leaving aside instrumental modes of delivery. Gestational age, mode of delivery (vaginal versus cesarean), and obstructed labor did not emerge as significant. In terms of the adjusted odds ratios from the logistic regression model, the three strongest predictors were birth weight, prolonged labor, and time of delivery. Increasing maternal height and baby's head circumference appeared to be protective.
|Table 4: Risk factors for birth trauma emerging as significant upon logistic regression analysis |
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Birth trauma related death was noted in only two babies out of total 390 neonatal deaths in the 8 months recruitment period giving an incidence of 0.51% (95% CI: 0.19-1.22%) among neonatal deaths. During the next 6 months, excluding 10 injured babies who were lost in follow-up, the majority recovered from their birth injuries except one baby with malunited humerus fracture requiring open surgery.
| Discussion|| |
Birth injuries denote impairment of the infant's body structure or function due to adverse events that occurred during the birth process.  While, in the United States itself, incidence of birth trauma varies from 0.2 to 37/1000 live birth; most recent study published from India showed incidence of 3.2/1000 live birth during 2009-2010. , In our study done in Kolkata, Eastern India, predominantly from "Bengali" population, the incidence documented is 15.4/1000 births (95% CI: 11.9-18.9). The fact that the result has been obtained through direct observation of a large cohort of in-hospital births is one of the strengths of the study.
In our study, majority was soft tissue injuries followed by scalp and skull injuries; minorities were deep organ injuries such as adrenal hemorrhage. This is broadly in conformity with results of earlier studies. ,,,,, The most commonly found extracranial bleeds in the neonate are cephalhaematomas.  In our study, there were 13 cases of cephalhematoma, among which one baby expired on day 3 of life due to associated skull fracture and intracerebral bleed. Clavicular fracture is the most common bony injury found in our study similar to what already reported. ,,,, Nerve injuries though uncommon, facial nerve palsy related to forceps application and brachial plexus injuries due to shoulder dystocia and breech extraction occur. ,,, In our study, there were four instances of facial palsy and three of Erb's palsy, all of which resolved within 6 months leaving no residual deformities.
Many risk factors for birth injury have been reported in literature. In our case, the female gender showed a stronger association with birth injury on univariate analysis, and this remained a significant risk factor on logistic regression. Linder et al.  have reported that the overall risk of birth trauma may not be related to fetal gender, although gender may be a predisposing risk factor for specific types of birth trauma and requires further exploration. Although higher incidence of birth injuries was noted in our study in babies born by cesarean section, difference was not significant upon multivariate analysis. Some study highlighted typical injuries during cesarean delivery while Iranian study contradicts and found more injuries during vaginal delivery as in our case, especially in instrumental vaginal delivery. , While, other studies such as Walsh et al. found no significant difference in incidence of trauma among cesarean delivery and instrumental vaginal delivery. 
Shorter maternal height, higher birth weight (especially above 4 kg), instrumental delivery, malpresentations, prolonged labor, and obstructed labor have been repeatedly identified as univariable predictors for birth trauma. ,,,,,,,, Similar factors were identified in our analysis, although the level of risk varied. Prolonged labor and instrumental delivery have been found to be the strongest risk factors, which is also in conformity with some earlier reports.  Forceps was found to be associated with high (73.97%) neonatal birth trauma in our study. Some recent studies in the year 2013, 2014, in developed countries highlighted the trend toward use of vacuum extractor as preferred mode of instrumental vaginal delivery in contrast to forcep with documented decrease in morbidities. ,, However, operator skill, availability of instrument, and clinical setting should always be emphasized prior to decision regarding the conduct of delivery.
Delivery during risk hours has been found to be an independent risk factor in an earlier study.  We found that delivery between 2:00 am and 8:00 am carried a higher risk of birth injury than at other hours may be because of less vigilance and fatigue of hospital staffs. Although larger neonatal head circumference has been identified as a risk factor,  the risk level was inconsistent between univariate and multivariate analysis in our study.
Birth trauma related death was noted in our study only 0.51% among total neonatal deaths which is almost corroborating with already published birth trauma-related mortality which is <2%.  Overall neonatal mortality was 8.2%, which is high, probably because of delivery of high-risk pregnancy in the highest level of referral Tertiary Care Hospital of our state. Incidence of birth trauma being higher in caesarean deliveries than in vaginal delivery in our study, it would have been worthwhile to identify the proportion of birth trauma following emergency cesarean section. Unfortunately, we did not capture these data and recognize it as a limitation of our study.
| Conclusion|| |
Data on birth trauma from developing countries are scarce, and the present study has generated some much-needed epidemiological data. Careful documentation as a routine practice and larger multicenter studies of birth trauma are required in future in order to chalk out prevention and mitigation strategies in the overall interest of maternal and neonatal health. Issues of birth trauma should be a part of obstetricians' basic education since its successful management includes special training, teamwork, and individual approach. In addition, an experienced neonatologist could improve these intentions by a fast and accurate diagnosis, and professional management of injured newborns.
It can be simply concluded that obstetrician's correct and timely decisions and expert manipulations cannot totally eliminate the appearance of birth injuries, but certainly can greatly reduce their number and serious consequences.
What is already known
The incidence with various predisposing maternal, neonatal, and labor related risk factors of birth trauma is identified from the Western world. However, prospective analysis of epidemiological factors from developing country like India is scarce.
What the study adds
Higher maternal age, shorter height, higher birth weight, prolonged labor (with associated instrumental delivery), malpresentations, and delivery during risk hours were identified as significant risk factors.
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]