Do maternal BMI and gestational weight gain equally affect the risk of infant hypoxic and traumatic events?

BACKGROUND: Small (SGA) and large (LGA) for gestational age infants have higher risks of infant morbidity when compared to those who are appropriate for gestational age (AGA). Increasing pre-pregnancy maternal BMI and gestational weight gain (GWG) are associated with higher risks of LGA and lower risks of SGA infants; however, their direct effects on infant morbidity are unknown. Therefore, we intended to 1) assess how maternal pre-pregnancy BMI, GWG, and birthweight (categorized as SGA, AGA or LGA) affect infant morbidity and 2) estimate at entry of care the risk of infant morbidity according to pre-pregnancy BMI and possible GWG. METHODS: we used Consortium on Safe Labor data, a retrospective observational cohort study collecting pregnancy and birth data from 2002 to 2008 in 12 US centers. The association between maternal BMI, GWG and infant morbidity was estimated in singleton gestations delivering ≥ 37 weeks using binomial logistic regression. Hypoxic composite neonatal morbidity was defined as any the following: stillbirth, neonatal death, resuscitation at birth, NICU admission, intracranial hemorrhage, PVH grade III and IV, neonatal seizures, NEC, meconium aspiration, CPAP or mechanical ventilation, RDS, and sepsis. Traumatic composite neonatal morbidity included shoulder dystocia or birth injuries. RESULTS: In this study of 110,594 mother-infant dyads, a total of 8,369 (7.6%) infants experienced hypoxic, while 2,134 (1.9%) developed traumatic morbidity. The risk of hypoxic morbidity among SGA, AGA and LGA infants increased when mothers were overweight (aOR 1.26 [95%CI 1.18-1.34]) or obese (class 1: aOR 1.3 [1.2-1.4]; class 2: aOR 1.7 [1.5-1.9]; class 3: aOR 1.8 [1.6-2]) as opposed to normal weight, and when GWG exceeded (aOR 1.08 [1.02-1.014]) rather than remained within recommendations. The risk of traumatic morbidity increased with maternal obesity (class 1: aOR 1.3 [1.1-1.5]), whilst it dropped with GWG below recommendations (aOR 0.7 [0.6-0.8]). The risk of hypoxic events estimated at entry of care increased with maternal overweight (aOR 1.27 [1.19-1.35]) or obesity (class 1: aOR 1.4 [1.2-1.5]; class 2: aOR 1.7 [1.5-1.9]; class 3: aOR 1.8 [1.6-2.1]), and with possible GWG above (aOR 1.09 [1.03-1.015]) recommendations. The risk of traumatic morbidity increased with overweight (aOR 1.1 [1-1.3]) or obesity (class 1: aOR 1.4 [1.2-1.6]; class 2: aOR 1.3 [1-1.6]), with possible GWG above (aOR 1.2 [1-1.3]), as opposed to below recommendations (aOR 0.7 [0.6-0.8]). CONCLUSIONS: While maternal pre-pregnancy BMI and GWG equally affected traumatic morbidity, the former had a greater impact on hypoxic complications. Therefore, weight control prior to pregnancy is at least as effective as avoiding excessive gestational weight gain to prevent neonatal morbidity.

Obstetric factors and neonatal outcomes of depressed skull fractures in newborns.

PURPOSE: To determine the obstetric factors affecting the development of depressed skull fracture in neonates. MATERIALS AND METHODS: This was a retrospectively cohort study on neonates born between July 2016 and August 2021. Neonates diagnosed with depressed skull fractures within one week of birth through X-ray and/or brain ultrasonography were included, and their mothers' obstetric characteristics were reviewed. RESULTS: There were 12 cases in 6791 live births. Five women were over 35 years old. All except two were nulliparous. Five cases were delivered from labor induction and others presented with spontaneous labor. Except for two cases, delivery occurred within an hour after full cervical dilatation. Two cases were assisted by vacuum. None displayed fetal distress signs such as low Apgar scores below 7, meconium staining, and umbilical cord pH under 7.2. All depressed fractures were found in the right parietal area. Three cases resulted in focal hyperechoic lesion in brain ultrasonography and two of them showed small hemorrhage-like lesion in magnetic resonance imaging. All depressed skull fractures improved within 6 months in followed X-rays or ultrasonography. CONCLUSIONS: There was no definitely associated obstetric condition for depressed skull fracture of neonates although nulliparous women were majority of the affected cases.

Prevalence and associated factors of maternal birth trauma following vaginal delivery at University of Gondar Comprehensive Specialized Hospital, North-West Ethiopia, 2022.

BACKGROUND: Maternal injury with any form of perineal trauma following vaginal delivery is very common which ranges globally from 16.2 to 90.4%. The frequency of Obstetric anal sphincter Injuries and the incidence of cervical laceration increases rapidly. However, in Ethiopia, there is limited evidence on the prevalence of maternal birth trauma and its determinant factors after vaginal delivery. OBJECTIVE: To assess the magnitude and associated factors of Maternal Birth Trauma after vaginal delivery at University of Gondar Comprehensive Specialized Hospital, Gondar, North-West Ethiopia, 2022. METHODS: An Institution based cross-sectional study was conducted among mothers with singleton vaginal delivery at University of Gondar Comprehensive Specialized Hospital from 9th May to 9th August 2022 among 424 study participants. Pre-tested semi-structured questioner was utilized. Epi-Data version 4.6 was used for data entry and exported to SPSS version 25 for data management and analysis. To identify the determinant factors, binary logistic regression model was fitted and variables with p-value < 0.2 were considered for the multivariable binary logistic regression analysis. In the multivariable binary logistic regression analysis, Variables with P-value < 0.05 were considered to have statistical significant association with the outcome variable. The Adjusted Odds Ratio (AOR) with 95% CI was reported to declare the statistical significance and strength of association between Maternal Birth Trauma and independent variables. RESULTS: A total of 424 mothers who delivered vaginally were included. The mean age of participants was 26.83 years (± 5.220 years). The proportion of birth trauma among mothers after vaginal delivery was47.4% (95%CI: 43.1, 51.7). Of different forms of perineal trauma, First degree tear in 42.8%, OASIs in 1.5% and Cervical laceration in 2.5% study participants. In the multivariable binary logistic regression analysis being primiparous (AOR = 3.00; 95%CI: 1.68, 5.38), Gestational age ≥ 39 weeks at delivery (AOR = 2.96; 95%CI: 1.57, 5.57), heavier birth weight (AOR = 12.3; 95%CI: 7.21, 40.1), bigger head circumference (AOR = 5.45; 95%CI: 2.62, 11.31), operative vaginal delivery (AOR = 6.59; 95%CI: 1.44, 30.03) and delivery without perineum and/or fetal head support (AOR = 6.30; 95%CI: 2.21, 17.94) were significantly associated with the presence of maternal birth trauma. CONCLUSION AND RECOMMENDATION: Maternal birth trauma following vaginal delivery was relatively high in this study. Prim parity, gestational age beyond 39 weeks at delivery, heavier birth weight, bigger head circumference, operative vaginal delivery and delivery without perineum and/or fetal head supported were factors affecting perineal outcome. The Ministry of Health of Ethiopia should provide regular interventional training as to reduce maternal birth trauma.

The Putti Sign Following Residual Brachial Plexus Birth Injury: Prevalence and Significance.

BACKGROUND: The Putti sign, a common deformity and complaint in children with brachial plexus birth injury (BPBI), stems from a glenohumeral (GH) abduction contracture. Despite recent clinical studies offering insights into this deformity, none have explored the prevalence of the Putti sign or its correlation with GH abduction contractures. METHODS: We conducted a prospective analysis of 238 patients (median age 7.5 years; range, 4.1-16.2) with residual BPBI seen in the clinic from December 2019 to December 2022. Epidemiological data, including demographics, palsy levels, modified Mallet scale sum, surgical history, and presence/absence of the Putti sign and glenohumeral adduction angle (GHADD), were collected. Patients were categorized into 4 age groups: 0 to 5 years (n=67), 6 to 10 years (n=102), 11 to 15 years (n=53), and 16 years and older (n=16). Results were expressed as medians (minimum-maximum), with frequency comparisons done using Pearson's chi-square analysis. Mann-Whitney U and Kruskal-Wallis tests were used for quantitative variable comparison, and receiver operating characteristic (ROC) analysis determined the threshold GHADD angle for Putti sign appearance. RESULTS: Main findings included: (1) 27% of patients with residual BPBI exhibited the Putti sign, (2) confirmed correlation between the Putti sign and GH adduction contractures, (3) Putti sign manifestation with GHADD angle measuring less than -5° because to abduction contracture, and (4) association between this deformity and reduced activities requiring external rotation. No significant differences in Putti sign prevalence were found across age groups. CONCLUSIONS: Our study underscores the common occurrence of the Putti sign in children with residual BPBI. It is important to note that we highlight its functional significance beyond cosmetic concerns. Contrary to prior literature, our analysis reveals functional impairment associated with the Putti sign. Although no age-based differences in Putti sign prevalence were observed, patients aged 0 to 5 years and 11 to 15 years showed more severe glenohumeral abduction contractures, possibly due to growth spurts. LEVEL OF EVIDENCE: Diagnosis IV.

A Rare Case:Transphyseal Distal Humerus Fracture in a Newborn.

Transphyseal fractures of the distal humerus are usually seen in children younger than 3 years of age and are considered as Salter-Harris Type I epiphysiolysis. Neonatal transphyseal distal humerus injuries are extremely rare. It usually occurs due to trauma during difficult labour but can also be seen after child abuse. Since the distal humerus is composed of cartilaginous tissue in newborns, it is difficult to make a diagnosis with direct radiography. Patients are often diagnosed with elbow dislocation. However, elbow dislocation is almost never seen under the age of 3 years. Transphyseal fractures can be seen as a result of manoeuvres performed to deliver the baby during difficult normal delivery. Transphyseal humeral injuries can also be seen after caesarean section, child abuse and falling on the hyperextended arm. Clinical symptoms include pain, swelling, ecchymosis and crepitation at the elbow. Pseudoparalysis is present due to pain. In children with a history of difficult birth or trauma, evaluation with direct radiography should be performed initially. Radiocapitellar line is distorted on radiographs and the elbow joint appears subluxated. The treatment algorithm for transfusional humeral fractures in neonates is varied. It should be remembered that patients in this age group have a tremendous healing capacity. In conservative treatment, 2-4 weeks of follow-up with a long-arm splint after reduction is sufficient. In addition, closed reduction-internal fixation or open reduction-internal fixation can be applied according to the amount of displacement of the fracture. Cubitus varus, osteonecrosis, growth disturbance, decreased range of motion, compartment syndrome, neurovascular injury and infection are the main complications seen after transfusional humeral fractures.

Neonatal complications and risk factors associated with assisted vaginal delivery.

To investigate neonatal injuries, morbidities and risk factors related to vaginal deliveries. This retrospective, descriptive study identified 3500 patients who underwent vaginal delivery between 2020 and 2022. Demographic data, neonatal injuries, complications arising from vaginal delivery and pertinent risk factors were documented. Neonatal injuries and morbidities were prevalent in cases of assisted vacuum delivery, gestational diabetes mellitus class A2 (GDMA2) and pre-eclampsia with severe features. Caput succedaneum and petechiae were observed in 291/3500 cases (8.31%) and 108/3500 cases (3.09%), respectively. Caput succedaneum was associated with multiparity (adjusted odds ratio [AOR] 0.36, 95% confidence interval [CI] 0.22-0.57, P < 0.001) and assisted vacuum delivery (AOR 5.18, 95% CI 2.60-10.3, P < 0.001). Cephalohaematoma was linked to GDMA2 (AOR 11.3, 95% CI 2.96-43.2, P < 0.001) and assisted vacuum delivery (AOR 16.5, 95% CI 6.71-40.5, P < 0.001). Scalp lacerations correlated with assisted vacuum and forceps deliveries (AOR 6.94, 95% CI 1.85-26.1, P < 0.004; and AOR 10.5, 95% CI 1.08-102.2, P < 0.042, respectively). Neonatal morbidities were associated with preterm delivery (AOR 3.49, 95% CI 1.39-8.72, P = 0.008), night-time delivery (AOR 1.32, 95% CI 1.07-1.63, P = 0.009) and low birth weight (AOR 7.52, 95% CI 3.79-14.9, P < 0.001). Neonatal injuries and morbidities were common in assisted vacuum delivery, maternal GDMA2, pre-eclampsia with severe features, preterm delivery and low birth weight. Cephalohaematoma and scalp lacerations were prevalent in assisted vaginal deliveries. Most morbidities occurred at night.Clinical trial registration: Thai Clinical Trials Registry 20220126004.

Obstetric claims in Finland 2012-2022-A nationwide patient insurance registry study.

INTRODUCTION: Maternal and infant mortality rates in Finland are among the lowest in the world, yet preventable obstetric injuries occur every year. The aim of this study was to describe obstetric claims, their compensation rates, and temporal trends of claims reported to the Patient Insurance center. MATERIAL AND METHODS: A nationwide, register-based study was conducted. Data consisted of obstetric claims reported to the Patient Insurance Center between 2012 and 2022. Data analyzed included the year of injury, compensation criteria, maternal age, birth hospital, delivery method, reported causes of injury, and maternal or neonatal injury. The data were analyzed with descriptive statistics and logistic regression models. RESULTS: A total of n = 849 obstetric claims were filed during the study period, of which n = 224 (26.4%) received compensation. The rate of claims was 0.15%, and the rate of compensation was 0.04% in relation to the total volume of births during the period. Substandard care was the most common (97.3%) criterion for compensation. There was a curvilinear increase in the claims rate and a linear increase in compensation rates from 2013 to 2019. More claims were filed and compensated for cesarean and vacuum-assisted deliveries than for unassisted vaginal deliveries. Delayed delivery (18.7%) and surgical technique failure (10.9%) were the most reported causes of injuries. Retained surgical bodies were the induced cause of injury with the highest rate of compensated claims (86.7%). The most common maternal injury was infection (17.9%) and pain (11.7%). Among neonatal injuries, severe (19.2%) and mild asphyxia (16.6%) were the most frequent. Burn injuries (93.3%) and fetal or neonatal death (60.5%) had the highest rate of compensated claims. CONCLUSIONS: The study provided new information on substandard care and injuries in obstetric care in Finland. An increasing trend in claims and compensation rates was found. Identifying contributors to substandard care that lead to fetal asphyxia is important for improving obstetric safety. Further analysis of the association of claims and compensation rates with operative deliveries is needed to determine their causality. Frequent review of obstetric claims would be useful in providing more recent data on substandard care and preventable injuries.

Indicated vs universal third-trimester ultrasound examination in low-risk pregnancies: a pre-post-intervention study.

BACKGROUND: In low-risk pregnancies, a third-trimester ultrasound examination is indicated if fundal height measurement and gestational age discrepancy are observed. Despite potential improvement in the detection of ultrasound abnormality, prior trials to date on universal third-trimester ultrasound examination in low-risk pregnancies, compared with indicated ultrasound examination, have not demonstrated improvement in neonatal or maternal adverse outcomes. OBJECTIVE: The primary objective was to determine if universal third-trimester ultrasound examination in low-risk pregnancies could attenuate composite neonatal adverse outcomes. The secondary objectives were to compare changes in composite maternal adverse outcomes and detection of abnormalities of fetal growth (fetal growth restriction or large for gestational age) or amniotic fluid (oligohydramnios or polyhydramnios). STUDY DESIGN: Our pre-post intervention study at 9 locations included low-risk pregnancies, those without indication for ultrasound examination in the third trimester. Compared with indicated ultrasound in the preimplementation period, in the postimplementation period, all patients were scheduled for ultrasound examination at 36.0-37.6 weeks. In both periods, clinicians intervened on the basis of abnormalities identified. Composite neonatal adverse outcomes included any of: Apgar score ≤5 at 5 minutes, cord pH <7.00, birth trauma (bone fracture or brachial plexus palsy), intubation for >24 hours, hypoxic-ischemic encephalopathy, seizure, sepsis (bacteremia proven with blood culture), meconium aspiration syndrome, intraventricular hemorrhage grade III or IV, periventricular leukomalacia, necrotizing enterocolitis, stillbirth after 36 weeks, or neonatal death within 28 days of birth. Composite maternal adverse outcomes included any of the following: chorioamnionitis, wound infection, estimated blood loss >1000 mL, blood transfusion, deep venous thrombus or pulmonary embolism, admission to intensive care unit, or death. Using Bayesian statistics, we calculated a sample size of 600 individuals in each arm to detect >75% probability of any reduction in primary outcome (80% power; 50% hypothesized risk reduction). RESULTS: During the preintervention phase, 747 individuals were identified during the initial ultrasound examination, and among them, 568 (76.0%) met the inclusion criteria at 36.0-37.6 weeks; during the postintervention period, the corresponding numbers were 770 and 661 (85.8%). The rate of identified abnormalities of fetal growth or amniotic fluid increased from between the pre-post intervention period (7.1% vs 22.2%; P<.0001; number needed to diagnose, 7; 95% confidence interval, 5-9). The primary outcome occurred in 15 of 568 (2.6%) individuals in the preintervention and 12 of 661 (1.8%) in the postintervention group (83% probability of risk reduction; posterior relative risk, 0.69 [95% credible interval, 0.34-1.42]). The composite maternal adverse outcomes occurred in 8.6% in the preintervention and 6.5% in the postintervention group (90% probability of risk; posterior relative risk, 0.74 [95% credible interval, 0.49-1.15]). The number needed to treat to reduce composite neonatal adverse outcomes was 121 (95% confidence interval, 40-200). In addition, the number to reduce composite maternal adverse outcomes was 46 (95% confidence interval, 19-74), whereas the number to prevent cesarean delivery was 18 (95% confidence interval, 9-31). CONCLUSION: Among low-risk pregnancies, compared with routine care with indicated ultrasound examination, implementation of a universal third-trimester ultrasound examination at 36.0-37.6 weeks attenuated composite neonatal and maternal adverse outcomes.

Neonatal birth trauma and associated factors in low and middle-income countries: A systematic review and meta-analysis.

Neonatal birth trauma, although it has steadily decreased in industrialized nations, constitutes a significant health burden in low-resource settings. Keeping with this, we sought to determine the pooled cumulative incidence (incidence proportion) of birth trauma and identify potential contributing factors in low and middle-income countries. Besides, we aimed to describe the temporal trend, clinical pattern, and immediate adverse neonatal outcomes of birth trauma. We searched articles published in the English language in the Excerpta Medica database, PubMed, Web of Science, Google, African Journals Online, Google Scholar, Scopus, and in the reference list of retrieved articles. Literature search strategies were developed using medical subject headings and text words related to the outcomes of the study. The Joana Briggs Institute quality assessment tool was employed and articles with appraisal scores of seven or more were deemed suitable to be included in the meta-analysis. Data were analyzed using the random-effect Dersimonian-Laird model. The full search identified a total of 827 articles about neonatal birth trauma. Of these, 37 articles involving 365,547 participants met the inclusion criteria. The weighted pooled cumulative incidence of birth trauma was estimated at 34 per 1,000 live births (95% confidence interval (CI) 30.5 to 38.5) with the highest incidence observed in Africa at 52.9 per 1,000 live births (95% CI 46.5 to 59.4). Being born to a mother from rural areas (odds ratio (OR), 1.61; 95% CI1.18 to 2.21); prolonged labor (OR, 5.45; 95% CI 2.30, 9.91); fetal malpresentation at delivery (OR, 4.70; 95% CI1.75 to 12.26); shoulder dystocia (OR, 6.11; 95% CI3.84 to 9.74); operative vaginal delivery (assisted vacuum or forceps extraction) (OR, 3.19; 95% CI 1.92 to 5.31); and macrosomia (OR, 5.06; 95% CI 2.76 to 9.29) were factors associated with neonatal birth trauma. In conclusion, we found a considerably high incidence proportion of neonatal birth trauma in low and middle-income countries. Therefore, early identification of risk factors and prompt decisions on the mode of delivery can potentially contribute to the decreased magnitude and impacts of neonatal birth trauma and promote the newborn's health.

Incidence, contributing factors and outcomes of birth injury among newborns in Africa: a systematic review of quantitative evidence protocol.

INTRODUCTION: Birth injury is a significant public health problem in Africa, with a high incidence and associated mortality and morbidity. Systematic reviews that indicate the incidence, contributing factors and outcomes of birth injury in Africa provide valuable evidence to policy-makers and programme planners for improving prevention and treatment strategies. Therefore, this review is aimed to evaluate the incidence, contributing factors and outcomes of birth injury among newborns in Africa. METHODS AND ANALYSIS: The data will be searched and extracted from JBI Database, Cochrane Database, MEDLINE/PubMed, CINAHL/EBSCO, EMBASE, PEDro, POPLINE, Proquest, OpenGrey (SIGLE), Google Scholar, Google, APA PsycInfo, Web of Science, Scopus and HINARI. Unpublished studies and grey literature will be searched from different sources. This systematic review will include quantitative observational studies, registry and census data, and experimental studies that report on the prevalence or incidence in Africa from 1 January 1990 to 30 September 2023. The Joanna Briggs Institute (JBI) quality appraisal checklist will be used to select eligible studies. Two researchers will independently appraise and extract the data from included studies and resolve discrepancies through discussion. Heterogeneity will be assessed using forest plots and the I2 statistic. If substantial heterogeneity is present, a random-effects model will be used to pool the data. Subgroup analyses will be used to explore the potential sources of heterogeneity. Publication bias will be assessed using funnel plots and Egger's regression test. The software package used to conduct the meta-analysis will be JBI SUMARI. An association will be considered significant if the p<0.05. ETHICS AND DISSEMINATION: Ethical clearance is not needed for this systematic review and the results will be shared with relevant stakeholders to maximise reach and impact. PROSPERO REGISTRATION NUMBER: CRD42023123637.

Ethnic background as a risk factor for permanent brachial plexus birth injury: A population-based study.

INTRODUCTION: Brachial plexus birth injury is the most common birth injury causing permanent disability in Finland. This study aimed to assess risk factors of a permanent brachial plexus birth injury and calculate the incidence. MATERIAL AND METHODS: This is a retrospective population-based study including all deliveries between 2006 and 2022 in Southern Finland. The number of children born, obstetric data, and migrant status were gathered from the registries of the Finnish Institute for Health and Welfare, and Statistics Finland. Race of the mothers of children with a permanent brachial plexus birth injury was recorded. The severity of permanent brachial plexus birth injury was assessed using the 3-month Toronto test score. A lower score was indicative of a more severe injury (scored 0-10). RESULTS: One hundred of the 298 428 children born during the 17-year study period sustained a permanent brachial plexus birth injury (0.34 per 1000). Mothers of children with a permanent brachial plexus birth injury had a higher body mass index (29 vs. 24 kg/m2) and their pregnancies were more often complicated by diabetes (28% vs. 12%), shoulder dystocia (58% vs. 0.3%), and/or assisted deliveries (45% vs. 10%) compared with all other mothers (p < 0.001). Thirty two of the 52 725 children born to migrant mothers had a permanent brachial plexus birth injury (0.61 per 1000). The incidence of permanent brachial plexus birth injury was 5.7 times higher among children of Black migrants from Africa (18/11 738, 1.53 per 1000) compared with children of native mothers (0.27 per 1000). Black mothers had a higher body mass index at the start of pregnancy (29 vs. 26 kg/m2, p = 0.02) compared with Caucasians. Children of Black mothers had a more severe injury compared with all others (p = 0.007) with a mean 3-month Toronto test score of 4.2 (range 0.0-6.5, SD ±1.6) vs. 5.6 (range 0.0-9.3, SD ±2.2). CONCLUSIONS: Shoulder dystocia and assisted delivery are the most important risk factors for a permanent brachial plexus birth injury. Black race was associated with a higher rate and a more severe permanent brachial plexus birth injury.

A Novel Operation Technique for Forearm Deformities in Patients with Brachial Plexus Birth Injury: Retrospective Analysis of 14 Patients.

Background: We aimed to evaluate the effectiveness of our novel operation technique that included radial shaft shortening plus supination producing osteotomy and transfer of the biceps brachii tendon to the brachialis tendon in patients with chronic radial head dislocation secondary to brachial plexus birth injury (BPBI). Methods: Fourteen patients with chronic radial head dislocation resulting from BPBI were included in this study, with a minimum 1-year postoperative follow-up period. All patients underwent the same surgical procedure. The range of motion of affected elbow was measured with a standard goniometer. The Mayo Elbow Performance Score (MEPS) was used to measure for evaluation of functional result of these patients. The affected elbow radiograph also obtained in the last visit for evaluation of compatibility of the radiocapitellar joint. Results: Fourteen patients (10 males and 4 females) were included in the study. The average age at the time of surgery was 7.2 (5-8) years and average follow-up was 73.2 ± 19 (36-131) months. Although the forearm active-passive pronation decreased, active-passive supination significantly improved postoperatively (p < 0.001). Ten patients had excellent MEPS results (90 and above), two patients with good results (75 and 80), one patient with fair (65) and one patient with poor result (55). Radiocapitellar reduction was achieved in 78.5% (11/14) of the patients. Conclusions: The novel surgical techniques that included radial shaft shortening plus supination producing osteotomy and transfer of the biceps brachii tendon to the brachialis tendon improved the functional outcomes of patients with chronic radial head dislocation secondary to BPBI. Level of Evidence: Level IV (Therapeutic).

Brachial plexus birth injuries: a multi-speciality approach. Commentary and opinions.

The management of brachial plexus birth injuries (BPBI) remains controversial and ever evolving. In this article, studies are examined to provide further insight into the ongoing controversies and debates surrounding BPBI. The articles are diverse and examine the topics of aetiology, demographics, reliability versus accuracy of measurements and surgical management. The management of BPBI may differ depending on resources. Outcome measures may also vary depending on geography. Future research should focus on developing consensus-validated measures and reproducible surgical techniques. These can then guide further population-based research and provide guidelines to minimize the incidence of BPBI.

Three-Dimensional Upper Limb Movement Analysis in Children and Adolescents With Brachial Plexus Birth Injury: A Systematic Review.

BACKGROUND: To synthesize the current evidence on clinical use of three-dimensional upper limb movement analysis (3D-ULMA) in children and adolescents with brachial plexus birth injury (BPBI). METHODS: MEDLINE, Embase, and Web of Science were searched for relevant studies up to April 2022. An automatic e-mail alert was installed to ensure no eligible article was missed. Articles evaluating 3D-ULMA in children and adolescents with BPBI were included. Covidence web-based platform was used for blind screening of eligible articles. Twenty-one observational studies with a final sample size of 609, encompassing 493 BPBI cases, met the inclusion criteria. Data were extracted using a custom form to support standardized extraction conforming to the Cochrane Checklist of items. Risk of bias was assessed using the Newcastle-Ottawa Scale, the Strengthening the Reporting of Observational Studies in Epidemiology checklist, and a specifically established quality assessment form for kinematic analysis studies. RESULTS: Study setups differed, including six different types of kinematic devices. Twelve studies used the (modified) Mallet positions for their 3D-ULMA. Throughout the studies, 3D-ULMA was used for various purposes. The Newcastle-Ottawa Scale scored 16 articles with five stars or more, indicating fair to moderate quality. CONCLUSIONS: This systematic review summarizes the different 3D-ULMA kinematic devices, test protocols, and their clinical use for BPBI. The use of 3D-ULMA provides valuable, objective, and quantified data to clinicians with regard to movement strategies; it complements existing clinical scales and can be implemented to evaluate effectiveness of therapy interventions. Implications for future research and clinical practice are discussed.

Advancing glenohumeral dysplasia treatment in brachial plexus birth injury: the end-to-side spinal accessory to suprascapular nerve transfer technique.

PURPOSE: Brachial plexus birth injury (BPBI) is a common injury with the spectrum of disease prognosis ranging from spontaneous recovery to lifelong debilitating disability. A common sequela of BPBI is glenohumeral dysplasia (GHD) which, if not addressed early on, can lead to shoulder dysfunction as the child matures. However, there are no clear criteria for when to employ various surgical procedures for the correction of GHD. METHODS: We describe our approach to correcting GDH in infants with BPBIs using a reverse end-to-side (ETS) transfer from the spinal accessory to the suprascapular nerve. This technique is employed in infants that present with GHD with poor external rotation (ER) function who would not necessitate a complete end-to-end transfer and are still too young for a tendon transfer. In this study, we present our outcomes in seven patients. RESULTS: At presentation, all patients had persistent weakness of the upper trunk and functional limitations of the shoulder. Point-of-care ultrasounds confirmed GHD in each case. Five patients were male, and two patients were female, with a mean age of 3.3 months age (4 days-7 months) at presentation. Surgery was performed on average at 5.8 months of age (3-8.6 months). All seven patients treated with a reverse ETS approach had full recovery of ER according to active movement scores at the latest follow-up. Additionally, ultrasounds at the latest follow-up showed a complete resolution of GHD. CONCLUSION: In infants with BPBI and evidence of GHD with poor ER, end-to-end nerve transfers, which initially downgrade function, or tendon transfers, that are not age-appropriate for the patient, are not recommended. Instead, we report seven successful cases of infants who underwent ETS spinal accessory to suprascapular nerve transfer for the treatment of GHD following BPBI.

The postnatal effects of perineal trauma on maternal psychological and emotional wellbeing: A longitudinal study.

OBJECTIVE: To examine the postnatal psychological health and parenting adjustment of primiparous women experiencing perineal trauma. STUDY DESIGN: Longitudinal cohort study assessing body image, perceptions of traumatic birth, psychological distress, perineal pain, impact upon parental tasks and mother-infant bonding at 6-12 weeks (n = 103) and 6-10 months postnatally (n = 91). Primiparous women were recruited following vaginal birth and perineal suturing in a UK-based maternity hospital. al. Comparisons made according to the objective classification of perineal trauma experienced; 1st/2nd degree tear, episiotomy, and Obstetric Anal Sphincter Injuries (OASI). RESULTS: At 6-12 weeks women with an episiotomy reported a more negative perception of their body image than those with OASI. Women with OASI or an episiotomy were more likely to have experienced birth as traumatic, and those with OASI reported more avoidance symptoms of post-traumatic stress and a greater negative impact on parenting tasks. At 6-10 months significantly more avoidance symptoms continued to be reported by those with OASI, whereas those with an episiotomy reported more anxiety related symptoms in general than those with OASI. CONCLUSIONS: OASI, whilst associated with traumatic birth and some early parenting impacts, may not be linked to general negative psychological outcomes when specialist routine follow-up care is provided. Psychological impacts for women with episiotomy may merit further input than currently provided. Consideration should be given with regards to widening the access to postnatal perineal care by extending the criteria for specialist follow up beyond those sustaining OASI.

Brachial plexus birth injury: advances and controversies.

While there is considerable spontaneous recovery in most cases of brachial plexus birth injury, many children are left with significant problems that may lead to lifelong functional limitations, loss of work and social isolation. Detailed treatment with the right strategy can provide very valuable improvement in function. Over the past few years, the clinical approach to brachial plexus birth palsy has entered a new era in both diagnostic and surgical treatment methods. This article reviews four areas of management, the role of imaging in defining the severity of the injury, the optimal timing of for nerve exploration and reconstruction in appropriate cases, the advantages and potential complications of nerve transfers, and the role of physiotherapy. Available evidence is considered. Although it is difficult to make clear and precise inferences on a subject where there are many variables and considerable uncertainties, some currently accepted views will be summarized.Level of evidence: V.