Maternal and neonatal trauma following operative vaginal delivery.

BACKGROUND: Operative vaginal delivery (OVD) is considered safe if carried out by trained personnel. However, opportunities for training in OVD have declined and, given these shifts in practice, the safety of OVD is unknown. We estimated incidence rates of trauma following OVD in Canada, and quantified variation in trauma rates by instrument, region, level of obstetric care and institutional OVD volume. METHODS: We conducted a cohort study of all singleton, term deliveries in Canada between April 2013 and March 2019, excluding Quebec. Our main outcome measures were maternal trauma (e.g., obstetric anal sphincter injury, high vaginal lacerations) and neonatal trauma (e.g., subgaleal hemorrhage, brachial plexus injury). We calculated adjusted and stabilized rates of trauma using mixed-effects logistic regression. RESULTS: Of 1 326 191 deliveries, 38 500 (2.9%) were attempted forceps deliveries and 110 987 (8.4%) were attempted vacuum deliveries. The maternal trauma rate following forceps delivery was 25.3% (95% confidence interval [CI] 24.8%-25.7%) and the neonatal trauma rate was 9.6 (95% CI 8.6-10.6) per 1000 live births. Maternal and neonatal trauma rates following vacuum delivery were 13.2% (95% CI 13.0%-13.4%) and 9.6 (95% CI 9.0-10.2) per 1000 live births, respectively. Maternal trauma rates remained higher with forceps than with vacuum after adjustment for confounders (adjusted rate ratio 1.70, 95% CI 1.65-1.75) and varied by region, but not by level of obstetric care. INTERPRETATION: In Canada, rates of trauma following OVD are higher than previously reported, irrespective of region, level of obstetric care and volume of OVD among hospitals. These results support a reassessment of OVD safety in Canada.

Risk factors for neonatal brachial plexus palsy attributed to anatomy, physiology, and evolution.

The inherent variable anatomy of the neonate and the uniquely-shaped maternal birth canal that is associated with the evolution of human bipedalism constitute risk factors for neonatal brachial plexus palsy (NBPP). For example, those neonates with a prefixed brachial plexus (BP) are at greater risk of trauma due to lateral neck traction during delivery than those with a normal or postfixed BP. Compared to adults, neonates also have extremely large and heavy heads (high head: body ratio) set upon necks with muscles and ligaments that are weak and poorly developed. Accordingly, insufficient cranial stability can place large torques on the cervical spinal nerves. In addition, the pelvic changes necessary for habitual bipedal posture resulted in a uniquely-shaped, obstruction-filled, sinusoidal birth canal, requiring the human fetus to complete a complicated series of rotations to successfully traverse it. Furthermore, although there are many risk factors that are known to contribute to NBPP, the specific anatomy and physiology of the neonate, except for macrosomia, is not considered to be one of them. In fact, currently, the amount of lateral traction applied to the neck during delivery is the overwhelming legal factor that is used to evaluate whether a birth attendant is liable in cases of permanent NBPP. Here, we suggest that the specific anatomy and physiology of the neonate and mother, which are clearly not within the control of the birth attendant, should also be considered when assessing liability in cases of NBPP.

Pathophysiologic Origins of Brachial Plexus Injury.

OBJECTIVE: To analyze the origins and consequences of cases of brachial plexus injuries and their relationship to shoulder dystocia. METHODS: We conducted a retrospective cohort study and identified all neonates with brachial plexus injury delivered at our institution between March 2012 and July 2019. A review was performed of the maternal and neonatal records of each neonate to identify obstetric antecedents, including the occurrence of shoulder dystocia and persistence of the injury. Experience of the delivering clinician was also examined. Statistical analysis was performed with the Fisher exact test, χ test for trends, and two-tailed t tests. RESULTS: Thirty-three cases of brachial plexus injury were identified in 41,525 deliveries (0.08%). Fourteen (42%) of these cases were not associated with shoulder dystocia; three (9%) followed cesarean delivery. Brachial plexus injury without shoulder dystocia was related to the absence of maternal diabetes, lower birth weights, and a longer second stage of labor. Persistent brachial plexus injury at the time of discharge was seen with equal frequency among neonates with (17/19, 89%, 95% CI 0.52-100%) and without shoulder dystocia (10/14, 71%, 95% CI 34-100%), P=.36). Whether brachial plexus injury was transient or persistent after shoulder dystocia was unrelated to the years of experience of the delivering clinician. Despite ongoing training and simulation, the already low incidence of brachial plexus injury did not decrease over time at our institution. CONCLUSION: Brachial plexus injury and shoulder dystocia represent two complications of uterine forces driving a fetus through the maternal pelvis in the presence of disproportion between the passage and the shoulder girdle of the passenger. Either or both of these complications may occur, but often are not causally related.

The relationship between the location of neonatal clavicular fractures and predisposing factors.

BACKGROUND: The aim was to investigate the maternal and fetal predisposing factors of clavicle fracture locations in newborns. METHODS: A retrospective evaluation was made of 77 clavicle fractures identified from a total of 33,480 live newborns between September 2016 and September 2018 at a single center in Turkey. Fractures were grouped according to the Allman classification: Group I mid third, Group II lateral distal third, Group III medial proximal third of the clavicle, respectively. Demographic features compared between the groups included maternal age, parity and height and infantile gestational age, gender, birth weight and length. Neonatal clinical features were also compared between the three groups and included mode of delivery, Apgar score, fracture laterality, time to diagnosis, mode of diagnosis, and presence of symptoms of brachial plexus palsy. RESULTS: There were no statistically significant differences between the three groups when the demographic characteristics of the mothers and newborns were compared. In terms of clinical characteristics Group 3 contained a higher proportion of patients with symptoms of brachial plexus palsy than Group 1 (61.5% versus 22%, p = 0.017). There was no statistically significant difference between Groups 2 and 3 and Groups 1 and 2. CONCLUSION: A significant association was found between the occurrence of brachial plexus palsy and fracture of the medial third of the clavicle (Allman type III).

Prevalence and predisposing factors of brachial plexus birth palsy in a regional hospital in Ghana: a five year retrospective study.

INTRODUCTION: Brachial plexus birth injury is one of the challenges associated with maternal delivery, with varying prevalence between countries. Brachial plexus birth injury poses negative health implications to children and also has socio-economic implications on families and the community as a whole. To treat brachial plexus birth injury, a multi-disciplinary treatment approach is recommended. Brachial plexus birth palsy (BPBP) is categorised into two-upper plexus injury (Erb's palsy) and lower plexus injury (Klumpke's palsy). These categories present with various degrees of injuries, with less severe injuries responding well to treatment and in most instances may resolve on their own, but serious and complicated injuries will require a multi-disciplinary treatment approach to treat and/or manage. Effective treatment and management depends on adequate knowledge of the disease condition. These include the risk factors and prevalence of brachial plexus birth palsy within a particular population at a specific period in time. The aim of this study was to determine the risk factors and the prevalence of a hospital based brachial plexus birth palsy within a five-year period (2013-2017). METHODS: A five-year retrospective study design was used. The study involved selection of all clients' diagnosed with brachial plexus birth palsy, where their gender, birth weight, complications at birth, type of brachial plexus suffered, mothers' diabetes status, mother's age, birth attendant, side of affectation, presentation at birth and mode of delivery were recorded. RESULTS: The prevalence rate of brachial plexus birth palsy was 14.7% out of a total of three hundred and twenty (320) cases reviewed over the study period in the Volta Regional Hospital. Erb's palsy was found to be the modal type of BPBP in this population (93.6%). CONCLUSION: There is the need to provide a nationwide education on the risk factors that predispose babies to brachial plexus birth palsy. There is also the need for frequent antenatal visit by pregnant women; this will help in the provision of best antenatal history, diagnostic investigation in determining the birth weight and safe mode of delivery.

Brachial Plexus Birth Injury in Elective Versus Emergent Caesarean Section: A Cohort Study.

OBJECTIVE: Although Caesarean section (CS) is protective for brachial plexus birth injury (BPBI), the incidence is not zero. A trial of labour with unfavourable intrauterine positioning is hypothesized to result in excessive force on the brachial plexus. The purpose of this study was to determine the risk of BPBI in emergent CS versus elective CS. METHODS: This was a retrospective cohort study. The authors used a nationwide demographic sample of all infants born in Canada from 2004 to 2012. BPBI diagnoses, risk factors, and national incidence data were obtained from the Canadian Institute for Health Information Discharge Abstract Database and Hospital Morbidity Database. The primary outcome was risk of BPBI in emergent CS versus elective CS. RESULTS: BPBI incidence was 1.24 per 1000 live births. Known biases may have underestimated the incidence. CS (elective and emergent) was protective for BPBI as compared with vaginal delivery (odds ratio [OR] 0.15; 95% confidence interval [CI] 0.13-0.18, P < 0.0001). Emergent CS was a moderately strong risk factor for BPBI versus elective CS (OR 3.14; 95% CI 1.79-5.10, P = 0.0001). CONCLUSION: Emergent CS is a moderate risk factor for BPBI compared with elective CS. Intrauterine positioning with a trial of labour may provide an antenatal etiology in these distinct cases.