Neonatal Birth Injuries: An Orthopedic Clinic Presentation

Birth trauma is defined as injury sustained by the neonate during the process of labour and delivery. The incidence in the united states is 29 per 1000 births [1]. With the improvement in obstetric care and reduction in perinatal mortality and birth asphyxia, there is a rising trend in the incidence of birth trauma [2]. Some birth injuries occurred more frequently than others. While minor ones usually heal without major intervention, the major ones are often referred. Certain factors such as birth weight, parity, prolonged labour, mode of delivery, fetal presentation and facility where baby was delivered are possible etiologic factors. The aim of this study is to determine the pattern of neonatal birth injuries presenting in a typical orthopedic clinic in a Nigerian hospital and the possible associated factors.


Introduction
Birth trauma is defined as injury sustained by the neonate during the process of labour and delivery. The incidence in the united states is 29 per 1000 births [1]. With the improvement in obstetric care and reduction in perinatal mortality and birth asphyxia, there is a rising trend in the incidence of birth trauma [2].
Some birth injuries occurred more frequently than others. While minor ones usually heal without major intervention, the major ones are often referred. Certain factors such as birth weight, parity, prolonged labour, mode of delivery, fetal presentation and facility where baby was delivered are possible etiologic factors. The aim of this study is to determine the pattern of neonatal birth injuries presenting in a typical orthopedic clinic in a Nigerian hospital and the possible associated factors.

Methodology
A prospective, hospital based cross sectional study carried out over a 2year period in a specialist Hospital, 46 neonates presenting to the Orthopedic clinic from July 2014 to June 2016 with birth injuries were assessed and data collection done using interviewer based semi-structured questionnaires. Statistical analysis was done using simple frequencies and chi-squared test for association.
Patients were managed and followed up.

Results
During the study period, a total of 46 babies with birth injuries and their mothers were recruited in the Orthopaedic Clinic. Table   1 revealed majority 69.6% of the mothers were in their third decade of life (20-29years). There were 23.9% who were in the ages of 31-40, while 6.5% of the mothers were older than 40 years. This is expected for the normal population as studies have shown that the usual age range for primigravida is 20-30 years [3]. The age range for the female reproductive age group is 15-49 years [4]. The table revealed that 67.4% of the babies with birth injuries were males while 32.6% were females. Studies have shown that there is a slight preponderance of males (52%) compared to females in the population [5]. As regards baby's weight, the highest percentage (39.1%) of babies with birth injuries have birth weight between 3.1-3.5kg, followed by babies with birth weight between 3.6-4.0kg which account for 21.7%. Also 19.6% of the babies were macrocosmic. While 50% have birth weight ≥3.6kg. Only 2.2% have low birth weight. This suggests that most of the babies at the time of delivery had normal weights with few exceptions and this correlates with other studies [6]. This suggests that birth injuries may occur in normal term neonates with normal birthweight and not just fetal macrosomia as it is always alleged that big babies have a hard time passing through the birth canal thus predisposing them to birth injuries [7]. As regards hospital/facility of delivery, the table shows that majority (67.4%) delivered at tertiary hospitals, while 8.7%, 10.9% and 13.0% were delivered at Primary health care centers, General hospitals and Private hospitals respectively. In a study done in Uganda, it was noted that women tend to deliver in the homes the center. In a study done in Canada in 2009, it was noted that planned home births that were supervised by registered midwives had low rates of brachial plexus injury similar to those attended by physicians in tertiary centers [9]. reported in other studies [11]. Delivery by Caesarean section is is the commonest mode of presentation [14]. however, the risk of birth trauma is higher with abnormal presentations [15] ( Table 2). Minor Cephalohematoma and skin injuries are usually not referred at birth as they often will not require any special intervention.
The four cases that presented were on account of size and delay in resorption. In order to accurately get the proportions of these injuries, screening at the point of birth in the labour ward or postnatal wards will better accurately document the proportion of these injuries. Some birth injuries will also be referred to other specialties such as severe subconjunctival hemorrhage to the ophthalmologists. Studies have shown that birth trauma has a higher risk of occurrence following prolonged labour which may manifest as cephalohematoma [14].  (Table 3).