Nigerian Journal of Paediatrics

Incidence and characteristics of neonatal birth injuries in Maiduguri North Eastern Nigeria

Niger J Paediatr 2018; 45 (2):99 - 105

ORIGINAL

Pius S

CC – BY Incidence and characteristics of

Ibrahim HA

Ibrahim BA

neonatal birth injuries in

Farouk AG

Maiduguri North-Eastern Nigeria

Machoko Y

Bello M

DOI:http://dx.doi.org/10.4314/njp.v45i2.5

Accepted: 3rd May 2018

Abstract :

Background:

Birth

<0.05 was considered statistically

injury is defined as impairment of

significant.

Simon P (

)

neonate’s body function that oc-

Results: Sixty one out of 1078

Halima AI, Bello AI

cur due to mechanical forces dur-

admitted to SCBU during the 12

Abubakar GF, Yenti M

ing the process of delivery. Inci-

months period of the study had

Mustapha B

dence of birth injury varies from

different types of birth injuries

Department of Paediatrics,

place to place, with place of deliv-

giving an incidence of 5.7/1000

University of Maiduguri Teaching

ery, experience of birth atten-

live births, p < 0.0001. Soft tissue

Hospital, Maiduguri, Nigeria

dants, and mode of delivery.

injury constituted the majority

Email:

Objective: To determine the inci-

accounting for

37/61 (60.7%),

simonpius2000@yahoo.co.uk

dence, characteristics of birth in-

closely

followed

sub-

jury in the Special Care Baby Unit

conjunctival haemorrhages 25/61

of the University of Maiduguri

(41.0%). Severe perinatal asphyxia

Teaching Hospital (UMTH).

also constituted significant propor-

Subjects and methods: This is a

tion of the birth injury 24/61

prospective observational study

(39.3%). Other central nervous

that was conducted in a Special

system (CNS) birth injuries in-

Care Baby Unit (SCBU) of the

cludes facial nerve palsy and Erb’s

University of Maiduguri Teaching

palsy 13.1% each. The commonest

Hospital. The subjects were re-

of the fractures was femoral bone

cruited between 1st January, 2016

fracture 9/61 (14.8%), followed by

and 31st December, 2016. Neona-

clavicular fracture 5/61 (8.2%). It

tal birth injury was diagnosed

was revealed that urea 2.5 mmol/L,

based on paediatrician or senior

total serum bilirubin (TSB) 12.4

registrar

examination.

Demo-

μ mol/L and random blood sugar

graphic variables: maternal age,

2.6mmol/L were deranged in those

maternal weight, and height, re-

neonates with three or more birth

productive and labour variables:

injuries and all the three parame-

prenatal care, parity, gestational

ters were statistically significant

age, presence and duration of

p<0.05. The common complica-

PROM, duration of labour, type

tions encountered in these patients

of delivery, and skill of delivery

were jaundice, anaemia and sepsis

attendance, while neonatal vari-

though were not statistically sig-

ables, includes: neonatal age, sex,

nificant P >0.05. Four patients

birth weight, length, Apgar score,

died, two with internal organ in-

and type of birth injury. The treat-

jury were, of which one with

ment administered to the patients

splenic rupture and the other one

were either medical management

with liver damage in addition to

such exchange blood transfusion

severe perinatal asphyxia died

in case of severe Jaundice com-

while the remaining two patients

plicating cephalhaematoma and/or

with severe perinatal asphyxia also

simple transfusion for anaemia

died with mortality rate of 6.6%.

without complication, photother-

Conclusion: The incidence of birth

apy, antibiotics, among others, or

injury has decreased overtime es-

surgical/orthopaedic treatment in

pecially in the affluent economy

the presence of surgical injury.

where obstetric and perinatal diag-

Statistical analysis was done using

nosis has remarkably improved,

SPSS version 16 (SPSS Inc., Illi-

but in the developing economy like

nois, Chicago USA). A P-value

ours as demonstrated in this study

100

such an improvement is yet to be

personnel will remarkably reduce

achieved. However education of

birth injury.

the general populace especially the

pregnant women so that they at-

Keywords: Neonatal, birth injury,

tend antenatal care and deliver at

incidence, Maiduguri

health facility with skilled health

Introduction

gaps in knowledge that can be improved upon.

Birth injuries are defined as impairment of neonatal

body function due to adverse

Events that occur at birth and can be avoidable and un-

Subjects and methods

avoidable. Despite meticulous and prompt prenatal care,

birth injuries usually occur particularly in prolonged and

This was a prospective observational study that was con-

difficult labour or foetal malpresentation.

ducted in the Special Care Baby Unit (SCBU) of the

In literature, the common types of birth injuries includes

University of Maiduguri Teaching Hospital, Maiduguri,

soft tissue injuries (bruises, petechiae, subcutaneous fat

Borno state Nigeria. The SCBU admits newborns as

necroses, ulceration and perforation), bleeding into sub-

referrals from other hospitals in addition to newborns

cutaneous tissues (cephalhaematoma, caput succeda-

delivered at the centre and admitted for neonatal birth

neum, subgaleal haemorrhage), intra-cranial haemor-

injuries and other various illnesses. The SCBU is 30 bed

rhages, central nervous system injuries (spinal cord in-

capacity run by two consultants, a senior registrar, two

jury, facial nerve palsy, brachial plexus injury such as

registrars, two interns and at least three nursing staffs on

Erb’s palsy and Klumpke’s paralyses), musculoskeletal

every shift.

injury (long bone and clavicular fracture and torticollis),

and hypoxic-ischaemic injury.

2-6

The subjects were recruited over a one year period be-

tween 1 January, 2016 and 31 December, 2016. Ethi-

The incidence of birth injuries varies widely from the

cal clearance was obtained from the hospital research

developed western countries to that of developing coun-

and ethical committee. An informed consent both writ-

tries. The incidence has decreased overtime in those

ten and verbal was obtained from the parents of each

affluent societies due to improved obstetric care and

baby before they were enrolled. One of the researcher

perinatal diagnosis. In United States, the incidence of

attended to the patients and information was obtained on

birth injury varies from 0.2-37/1000 live birth, while

7-9

the demographic variables: maternal age, maternal

the incidence reported from India ranged from 3.2-

weight, and height, reproductive and labour variables:

15.4/1000 livebirth. In Africa, statistics on birth injuries

prenatal care, parity, gestational age, prolong rupture of

are scarce, however studies done in some African coun-

amniotic membrane (PROM) >18 hours, duration of

tries like Mali and Morocco revealed frequencies of

PROM, induction of labour, shoulder dystocia, breech

0.68% and 0.26% respectively, while report from Egypt

presentation, prolong /obstructed labour, mode of deliv-

showed prevalence of up to 17%.

11, 12

Just like other

ery, and skill of delivery attendants, while neonatal vari-

African countries, study on birth injuries from Nigeria is

ables, included: age, sex, birth weight, length, head cir-

scarce, one study by Adegbehingbe and co-workers,

cumference, Apgar score, and types of birth injuries.

from Ile-Ife South-Western Nigeria reported birth inju-

After full physical examination by the researchers con-

ries by types and frequencies as follows; commonest

cerned, diagnosis of neonatal birth injury was made sup-

types were skeletal fractures 50(58.8%), brachial plexus

ported by ultrasonographic and radiologic investigation

injury 33(38.8%) and cerebral palsy 2(2.4%). Fracture

among others where necessary. Neonatal asphyxia was

of the clavicle were 23(46%); femur 12(24%), humerus

diagnosed based on clinical evidence (low Apgar score

11(22%) and radius/ulnar fracture 4(8%), others were

at 1 and 5 minute, need for resuscitation, hypotonia,

brachial injuries which includes Erb's palsy 31(93.9%)

seizure, Acidosis) and radiological evidence where sus-

and Klumpke’s palsy 2(6.1%).

picion of skeletal injuries were entertained. The treat-

ment administered to the patients were either purely

Shorter maternal height, higher birth weight (weight> 4

medical management such exchange blood transfusion

kg), instrumental delivery, malpresentations, prolonged

in case of severe cephalhaematoma and/or simple blood

labour, and obstructed labour and maternal age<16 or

transfusion for moderate anaemia, phototherapy, antibi-

>35 years have been identified as common risk factors

otics, intravenous fluid and oxygen therapy among oth-

of birth injuries.

10,14-17

While it is true that the overall

ers, or in the presence of surgical/or orthopaedic injuries

incidence of birth injuries has declined with improve-

such as lacerations were stitched and fractures/

ments in obstetrical care and prenatal diagnosis in most

dislocations had application of hip spicer cast, skin trac-

affluent societies, such cannot be attested to in develop-

tion and/or plaster of Paris (POP) as appropriate treat-

ing countries like Nigeria, also to the best of our knowl-

ment, see photograph H below. Outcome of the patients

edge such as study has not been reported in the last dec-

such as whether patients got well and discharged home,

ade in Nigeria and none has ever been undertaken in this

left against medical advice or died were all documented.

sub-region of the country. This informed the reason to

The study was also conducted in strict compliance with

undertake this study in order to determine the incidence,

1945 Helsinki declaration on study involving human

characteristics of neonatal birth injuries and to identify

subjects.

101

Statistical analysis

Table 1: Distribution and characteristics of birth injuries

Neonatal variables

Number

% of birth injuries

Statistical analysis was done using SPSS version 16

Gestational Age (weeks)

(SPSS Inc., Illinois, Chicago USA). Tables and charts

< 37

11.5

were used to present simple descriptive statistics, Stu-

86.9

dent t-test was used to compare mean values between

> 42

1.6

groups and Chi squared test was used for testing asso-

Infant Weight (gm)

ciation between categorical variables. A P-value <0.05

< 1000

1.6

was considered statistically significant.

1000-1499

4.9

1500-2499

11.5

2500-4000

73.8

>4000

8.2

Mode of Delivery

Results

SVD

59.0

23.0

The total number of neonates admitted into the special

Vacuum/Forceps

18.0

care baby unit (SCBU) over the one year study period

Place of Delivery

was 1078. The Total number of neonates with birth in-

Home

4.9

jury accounted for 61.The incidence of birth injury fol-

PHC

16.4

lowing mode of birth were; 4.3%, following vaginal

Private Health Facility

1.6

deliveries (including vacuum and forceps) and 1.4%

14.8

following caesarean sections. The overall incidence in

Teaching Hospital

62.3

this study was 5.7/1000 live birth, p=0.0001, this is as

Delivery Attendants

shown in figure 1. There was a predominance of male

TBA

1.6

sex of 40 versus 21 female giving a ratio of 1.9:1.

Mid-wife/Nurse

57.4

Twenty three of the patients (38.0%) were brought from

CHEW

19.7

Obstetric Residents

4.9

following home deliveries or referred from private

Consultants

16.4

health facilities, primary health care or from general

Duration of Admission (days)

hospital, while the remaining 38 patients (62.3%) were

< 7

6.6

delivered at tertiary health facility where the study was

7-13

34.4

conducted. Of these patients 20/38 (52.6%) were re-

14-21

21.3

ferred to the labour ward of the study centre in second

>21

37.7

stage of labour as difficult/obstructed labour. The gesta-

SVD=spontaneous vaginal delivery, CS=caesarean section, PHC=

tional age ranged between 30weeks to 43 weeks with

primary health care, GH=general hospital, TBA=traditional birth atten-

mean of 38.1±2.4 weeks, the weight ranged between

dants, CHEW=community health extension workers

900g to 5700g with mean of 3000±898.2g. Of all the

patients only 5 (8,2%) had weight greater 4000g while

Table 2: Types and frequencies of birth injury

46 patients (75.4%) the weight was within normal range,

Types of birth injury

two third of the patients had ≥ 3 birth injuries. Figures A

Soft tissue trauma

Frequency*

% of all

-H show pictures of clinical images of the various types

injuries

of birth injuries sustained and management during the

Facial and skin bruises

60.7

period of the study.

Sub conjunctival haemorrhage

41.0

Ecchymoses (bluish discoloration of

24.6

Table 2: Shows the frequency and types of birth injuries.

skin)

Soft tissue injury constitute the majority accounting for

Fat necrosis

16.4

Skin laceration

11.5

37/61 (60.7%), closely followed by sub-conjunctival

Scrotal/Labial trauma

6.6

haemorrhage 25/61 (41.0%). Severe perinatal asphyxia

Cephalhaematoma

16.4

also constituted significant proportion of the birth inju-

Caput succedenum

37.7

ries 24/61 (39.3%). Other central nervous system (CNS)

Subgeleal haemorrhage

13.1

injuries included facial nerve palsy and Erb’s palsy each

Ischaemic-Hypoxic trauma

constituting 13.1%. The commonest of the fractures was

Asphyxia

39.3

femoral 9/61 (14.8%), followed by clavicular fracture

CNS trauma

5/61 (8.2%). Four patients died, two with internal organ

Facial nerve palsy

13.1

injury were, of which one with splenic rupture and the

Erb’s palsy

13.1

Klumpke’s paralysis

3.3

other one with liver damage in addition to severe perina-

Fractures

tal asphyxia died while the remaining two patients with

Mandibular fracture

1.6

severe perinatal asphyxia also died with mortality rate of

Clavicular fracture

8.2

6.6%.

Femural fracture

14.8

Humeral fracture

6.6

Skull fracture

1.6

Internal Organ injury

Liver rupture

1.6

Splenic rupture

1.6

*some patients had multiple birth injuries

102

Table 3. Shows common laboratory and metabolic pro-

A. Lt parietal scalp

files of the patients withless than two birth injuries were

ulceration due

compared with those greater than two birth injuries. It

forcep delivery

shown that urea 2.5 mmol/L, total serum bilirubin (TSB)

12.4 μ mol/L and random blood sugar 2.6mmol/L were

deranged in those neonates with three or more birth inju-

ries and all the three parameters were statistically sig-

nificant p<0.05. The other complications encountered in

these patients were jaundice, anaemia and sepsis though

not statistically significant P >0.05. The pictures (A-H)

photographed below that shown various types of birth

injuries treated by the research team with 93.4% suc-

cess.

B. Lt humeral

fracture on X-

Table 3: Laboratory profiles and complications associ-

ray

ated with birth injuries

Number of birth injuries sustained by the patients

Variables

1-2 birth

≥3 birth

t-test

p-value

injury

Metabolic derrangement

Urea (mmol/L)

4.1

6.5

1.449

0.038*

Creatinine ( μ mol/L)

99.8

109.8

0.693

0.211

Calcium (mg/dL)

3.0

2.8

0.978

0.358

TSB ( μ mol/L

8.9

12.4

1.391

0.014*

C. Bilateral femoral

Conjugated SB ( μ mol/

4.8

6.4

0.285

0.461

fracture

PCV (%)

46.7

50.7

1.643

0.383

Complications associated with birth injury

Hypoglycaemia (RBS

8 (42.1)

18 (40.6)

1.016

0.027*

<2.6mmol/L)

Anaemia( PCV<35%)

8 (42.1)

22 (52.4)

0.553

0.457

Jaundice(>10mg/dL)

9 (47.4)

26 (61.9)

1.130

0.288

Convulsion

3 (15.8)

16 (38.1)

3.035

0.081

Sepsis

8 (42.1)

27 (64.3)

2.632

0.105

*p-value <0.05, PCV=packed cell volume, TSB=total serum bilirubin,

D. Facial bruises

RBS=random blood sugar

Fig 1: Incidence of Birth injury by birth method

G. Rt parietal

cephalhaematoma

Fig 2: Frequencies of birth injury with increase in number of

injuries per patients.

H. Neonate with

Both femoral frac-

ture on gallore’s

traction

103

Discussion

observed high incidence in our teaching hospital com-

pare to peripheral hospitals.

Birth injury incidence varies widely, while the morbidity

In our study centre, the spectrum of common types of

and mortality from birth injury has fallen to as low as

birth injuries were soft tissue injuries which includes

2% of neonatal mortality and 3% of neonatal morbidity

facial and skin bruises (60.7%), subconjunctival haem-

in the affluent societies which reflects the technological

orrhage (41.0%), caput succedenum (37.7%) and other

advancement of their Obstetric care. The incidence

birth injuries considered as part of soft tissue injuries

ranges from as low as 3.16/1000 live birth as reported

which includes cephalhaematoma (16.4%) and subgaleal

by Solanen and co-workers from Finland. In the devel-

haemorrhage (13.1%). These were largely in conformity

with the findings by Linder et al and Hailu et

oping countries the incidence is still relatively high as

al. Unlike other reports, intra-cranial bleeding was not

exemplified by report of 41.16/1000 live birth from Iran

by Hagiehe et al.

encountered. Hypoxic-ischaemic (encephalopathy) in-

jury due to severe perinatal asphyxia (39.1%) was high

In this study the overall incidence was 5.7/1000 live

in this study, much higher than most of the reported

cases from other studies.

1, 15,24

birth, while the incidence based on mode of delivery

We speculateprobably the

were: spontaneous vaginal delivery4.3/1000 live birth,

high incidence of hypoxic-ischaemic injury in our study

and that by operative/assisted birth was 1.4/1000 live

is because most of the patients were delivered by mid-

birth p<0.001, this was significantly lower than the re-

wife/nurse, though they were referred from peripheral

port by Hagiehe at al from Iran, however this was still

health facilities due to complication.

higher than report from Finland. This marked difference

between our finding and that of Hagiehe at al was proba-

Birth injuries involving the nervous system in this study

include the facial nerve palsy (7

bly because their study was conducted over three year

cranial injury) in

period while ours was over one year which was smaller

(13.1%), brachial plexus injuries including Erb’s palsy 8

than their study population. The incidence in our study

(13.1%) and Klumpke’s paralysis 2(3.3%). This finding

is similar to that reported by Warke et al and is said to

was also lower than that by Abedzadeh-Kalahroudi at

al who reported 22/1000 live birth, but this finding was

result from pressure due to forceps application for deliv-

higher than 3.26 per 1000 live birth as report by Wrake

ery causing facial asymmetry and weakness on the af-

at al from Indian Hospital. The incidence in this study

fected side of the face; brachial plexus injury resulting

was still higher than the incidences reported from Ma-

from shoulder dystocia, breech extraction, or hyper ab-

duction on the neck in cephalic presentation. Fractures

liand Morocco found0.68% , 0.26% and that from Cam-

eroon respectively.

11,20

of femur and humerus is said to be rare in literature,

while clavicular fracture was the commonest.

26, 27

How-

We report in this study that birth injuries occur among

ever in this study, femoral fracture was the commonest

term neonates in 86.9% of cases and among those who

(14.8%), followed by clavicular fracture (8.2%) and

weigh between 2500-4000 grams this was in contrast to

humeral fracture was 6.6%, this is lower in comparison

the report by Borna et al

who reported birth injury

to other reports.

8, 28,29

In our study there was each a case

among post term and those with larger weight at birth,

of liver and splenic rupture with intra-abdominal haem-

however it conforms to the report by Keita et al. Birth

orrhage which were diagnosed by abdominal ultrasound

injury was more among neonates delivered vaginally

scan, both patients were referred from a primary health

and those attended to by Mid-wives/Nurses, and was

care centre and in addition both had hypoxic – ischaemic

higher among those delivered in study centre compared

encephalopathy and expired shortly after admission, this

to those delivered at peripheral health facilities. The

conforms similar report in literature especially in diffi-

cult breech deliveries.

reason probably is because most of the patients deliv-

ered at the study facility were referred cases of compli-

cated labour and attempted vaginal delivery by mid-wife

The common metabolic derangement encountered in this

before intervention was made. This is similar to the re-

study were azotaemia, urea of (6.5mmol/L), in those

port by Mosavat et al and Warke et al

who also re-

patients with more than two birth injuries (p = 0.038),

ported that birth injuries were related to place of deliv-

elevated serum bilirubin among neonates with birth inju-

ery, education of the birth attendants, mode of delivery

ries 3 or more this was also statistically significant (p =

among others.

0.014). Other complications were; hypoglycaemia (RBS

< 2.1mmo/l), which was also statistically significant, (p

In our study many women especially those who are un-

< 0.027). Others were jaundice (61.9%), anaemia

booked decline operative delivery such C/S, vacuum,

(52.4%), sepsis (42.1%) and convulsions (15.8%), but

forceps due fear from cultural believe and they prefer

were not statistically significant (p > 0.05). This report

is inconsonance with the report by Andreas

trail of labour and in most instances it gets complicated

and Ma-

dan et al .

before intervention is employed. The neonates most of-

These complications were not unexpected

ten had suffered birth injury as is seen in many develop-

especially in those neonates that had birth asphyxia,

ing countries with poorly equipped health facili-

cephalhaematoma and septicaemias. Out of 61 patients

ties. Also in this study a substantial number of birth

studied 4 died, which constituted 6.6 % of the cases,

injuries were mainly among those delivered to mothers

while 93.4% were discharged home with no apparent

referred to the centre due to difficult second stage or

complication, as at the second follow up at 3 months of

complicated labour. This may be the reason why we

life.

104

Conclusion

at health facilities that can handle high risk pregnancies

that may result in birth injuries.

The incidence of birth injury has decreased overtime

especially in the affluent societies where obstetric and

perinatal care has remarkably improved, but in the de-

Acknowledgement

veloping societies like ours, as has been demonstrated in

this study such improvement is yet to be achieved. In the

The authors are particularly grateful to the staff of the

same vein birth injuries may be unavoidable even in the

Special Care Baby Unit and the Medical Information

optimal condition of standard obstetric care and diagno-

Management Department of UMTH for their corpora-

sis, and in the absence of apparent risk factors. Issues of

tion during the study.

birth injuries should be high in the minds of obstetri-

cians, neonatologists, mid-wives who conduct deliveries

Conflict of interest: None

and the general public especially the pregnant women be

Funding: None

educated on antenatal care clinic attendance and delivery

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