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Hospital Harm: Birth Trauma

Birth injuries are those sustained during the birth process, which includes labor and delivery. They may be avoidable, or they may be unavoidable and occur despite skilled and competent obstetric care, as in an especially hard or prolonged labor or with an abnormal presentation (Prazad et al., 2019).

Topics
  • Patient safety
  • Hospital harm
Audience

  • Point of care provider

  • Quality or safety improvement lead

  • Policy advisor or analyst

Goal

Reduce the incidence of injuries to the newborn during non-instrumented or instrument-assisted vaginal delivery, or Caesarean section.

Overview

Healthcare Excellence Canada has developed this Hospital Harm Improvement Resource – a compilation of resources to support patient safety and improvement efforts.

Since 1981, because of refinements in obstetric techniques and the increased use of cesarean deliveries over difficult vaginal deliveries, a dramatic decline has occurred in birth injuries as a cause of neonatal death. Statistics reported for 2013-2014 did not cite birth injury as one of the 10 leading causes of postnatal death. Despite a reduction in related mortality rates, birth injuries still represent an important source of neonatal morbidity and neonatal intensive care unit admissions. Of particular concern are severe intracranial injuries after vacuum-assisted and forceps vaginal delivery and failed attempts at instrument-assisted vaginal delivery. Although many injuries are mild and self-limited, others are serious and potentially lethal (Prazad et al., 2019).

The incidence of neonatal injury resulting from difficult or traumatic deliveries is decreasing due to increasing use of cesarean delivery in place of difficult versions, vacuum extractions, or mid- or high-forceps deliveries. There is an increased risk of trauma when the infant is large for gestational age which is sometimes associated with maternal diabetes, or when there is a breech or other abnormal presentation, especially in a primipara (Stavis, 2019).

On the basis of frequencies alone, some of the major findings of Pressler's research, Classification of major newborn birth injuries, can be highlighted. For example, of the 20 major categories of neonatal injuries cited, eight (40 per cent) involve blood vessels and some type of hemorrhage. Nerves or the nervous system is involved in six (30 per cent) of the injuries, and a major organ is also involved in six (30 per cent) of the injuries. Only five (24 per cent) of the injuries are the result of some type of bone fracture. The cause of injuries is thought to be associated with the occurrence of shoulder dystocia in six (30 per cent) of the cases. Use of instrumental techniques (e.g., forceps or vacuum extractors) is stated as being involved in at least 11 (55 per cent) of the injuries. Six (30 per cent) of the birth injuries were reported as leading to a potentially fatal prognosis (Pressler, 2008).

Categories and related sub-categories of common birth injuries include (Stavis, 2019):

  • Head injury is the most common birth-related injury and is usually minor, but serious injuries sometimes occur.

  • Head molding

  • Scalp abrasions

  • Caput succedaneum

  • Subgaleal hemorrhage*

  • Cephalhematoma*

  • Depressed skull fractures

  • Facial Nerve Injury* - The facial nerve is injured most often. Although forceps pressure is a common cause, some injuries probably result from pressure on the nerve in utero.

  • Brachial Plexus Injuries* - frequently follow lateral stretching of the neck during delivery caused by shoulder dystocia, breech extraction, or hyperabduction of the neck in cephalic presentations.

  • Erb palsy

  • Klumpke palsy

  • Involvement of the entire plexus

  • Phrenic Nerve Injuries* - Most phrenic nerve injuries (about 75 per cent) are associated with brachial plexus injury. Injury is usually unilateral and caused by a traction injury of the head and neck.

  • Spinal Cord Injury* - Trauma usually occurs in breech deliveries after excess longitudinal traction to the spine.

  • Intracranial Hemorrhage - Hemorrhage in or around the brain can occur in any neonate but is particularly common among those born prematurely; about 25 per cent of premature infants < 1500 g have intracranial hemorrhage.

  • Fractures* - Midclavicular fracture, the most common fracture during birth, occurs with shoulder dystocia and with normal, nontraumatic deliveries.

  • Soft -Tissue Injuries - All soft tissues are susceptible to injury during birth if they have been the presenting part or the fulcrum for the forces of uterine contraction.

*related to instrument-assisted delivery.

The incidence of birth injuries has dramatically decreased in the last two decades. Macrosomia and instrumental deliveries are major risk factors for birth injuries. Forceps use is the most common cause of facial nerve injury and is usually self-limited. Erb palsy is the most common brachial plexus injury. Shoulder dystocia is a major risk factor for brachial plexus injury. Planned cesarean delivery for breech presentation decreases mortality and morbidity. Posterior fossa hematoma can cause brain stem compression, leading to respiratory compromise (Akangire & Carter, 2016).

Now that forceps are used less frequently (e.g., especially use of mid- and high forceps), many of the injuries that were common before 1966 (e.g., skull fractures, facial bone fractures, femur fractures, facial) palsy, and cervical spine injuries are rarely seen in the United States today. Breech deliveries are less likely to be completed vaginally, and cesarean deliveries can be performed using a transverse incision instead of a midline incision approach. Nearly half of major birth injuries and serious negative outcomes are potentially avoidable with early detection and intervention. To avoid specific negative outcomes, various evaluative techniques, such as perinatal history, physical examination, radiographs, paracentesis, ultrasonography, computerized tomography scans, and magnetic resonance imaging, can be used to predict more accurately the abnormalities that place the fetus at high risk for major birth injuries. However, predicting the likelihood of an injury's occurrence does not guarantee that it will not happen, but instead may help lessen the severity of the injury approach (Pressler, 2008).

When assisted vaginal birth is deemed to have a higher risk of not being successful, it should be considered a trial of assisted vaginal birth and be conducted in a location where immediate recourse to Caesarean delivery is available (Hobson et al., 2019).

Performing a Caesarean section with extraction of a deeply impacted fetal head out of the maternal pelvis is technically challenging even for experienced obstetricians. The difficulty for the surgeon is to disengage the impacted head by hand due to a lack of space between the muscular and bony maternal pelvis and the deeply impacted fetal head. This procedure is associated with serious neonatal complications, for instance skull injuries causing cerebral haemorrhage and newborn hypoxia that result in higher neonatal admission rates. Head pushing is the most commonly practiced technique. However, reverse breech extraction has gradually been given higher priority. Recently assessed neonatal outcome show less morbidity after reverse breech extraction compared to the head pushing method for obstructed labour. The beneficial maternal-fetal results of performing the reverse breech procedure indicate that it is a reliable alternative to the standard head pushing method and should preferably be used in deeply impacted fetal head situations during Caesarean section in advanced labour (Lenz et al., 2019).

Risk Factors and Related Injuries

Importance to Patients and Families

'I can't forget the horror of my son's birth'

Despite medical advancements, childbirth is a major cause of post-traumatic stress disorder – and yet nobody talks about it. Leah McLaren tells the harrowing story of the arrival of her second child – and her fight for treatment and support (McLaren, 2017).

https://www.theguardian.com/lifeandstyle/2017/may/07/i-cant-forget-the-horror-of-my-sons-birth-post-traumatic-stress-disorder-childbirth

Clinical and System Reviews, Incident Analyses

Given the broad range of potential causes of birth trauma, in addition to recommendations listed above, we recommend conducting clinical and system reviews to identify latent causes and determine appropriate recommendations.

Occurrences of harm are often complex with many contributing factors. Organizations need to:

  1. Measure and monitor the types and frequency of these occurrences.

  2. Use appropriate analytical methods to understand the contributing factors.

  3. Identify and implement solutions or interventions that are designed to prevent recurrence and reduce risk of harm.

  4. Have mechanisms in place to mitigate consequences of harm when it occurs.

Measures

Vital to quality improvement is measurement, and this applies specifically to implementation of interventions. The chosen measures will help to determine whether an impact is being made (primary outcome), whether the intervention is actually being carried out (process measures), and whether any unintended consequences ensue (balancing measures). In selecting your measures, consider the following:

You may use different measures or modify the measures described below to make them more appropriate and/or useful to your particular setting. However, be aware that modifying measures may limit the comparability of your results to others.

Evaluate your choice of measures in terms of the usefulness of the final results and the resources required to obtain them; try to maximize the former while minimizing the latter.

Whenever possible, use measures you are already collecting for other programs.

Try to include both process and outcome measures in your measurement scheme.

Discharge Abstract Database

Discharge Abstract Database (DAD) Codes included in this clinical category: A04: Birth Trauma

Concept: Injuries to the newborn during non-instrumented vaginal delivery identified during the birth episode of care.

Notes: Refer to D04: Birth Trauma for injuries during instrument-assisted or Caesarean section delivery.

Discharge Abstract Database

Discharge Abstract Database (DAD) Codes included in this clinical category: D04: Birth Trauma

Concept: Injuries to the newborn during an instrument-assisted or Caesarean section delivery.

Notes: Refer to A04: Refer to A04: Birth Trauma for injuries during vaginal delivery without the assistance of instruments.

Success Stories

The Salus Global Corporation has its roots in the successful launch of the MOREOB (Managing Obstetrical Risk Efficiently) Program, created by Dr. J. Kenneth Milne and his team during his tenure as acting Executive Vice President of the Patient Safety Division of the Society of Obstetricians and Gynaecologists of Canada (SOGC). The program was successfully piloted in 2002 to hospital obstetrical units in Canada and demand grew rapidly over the next few years. In 2007, seeking a strategic partner to help with geographic expansion and to bring the underlying principles embedded in the MOREOB Program to other clinical areas, the SOGC approached the Healthcare Insurance Reciprocal of Canada (HIROC). The two entities acted upon their common interest of improving patient safety and formed Salus Global Corporation (Salus Global) in July of that year (Salus Global, n.d.).

The MOREOB program is a comprehensive patient safety and performance improvement program for interprofessional obstetrical teams. The program has now been delivered in over 300 hospitals in Canada and the US and to more than 16,000 participants in the past 12 plus years. It has made a significant difference in clinical outcomes for mother and baby and in the way healthcare teams function together. The primary focus of the MOREOB Program is improving clinical outcomes. To date, there has been a 10 per cent reduction in severe infant mortality; 24 per cent reduction in infant morbidity; 33 per cent reduction in Hypoxic Ischemic Encephalopathy; and 77 per cent reduction in the number of newborns transferred to another hospital after a low-risk pregnancy and elective birth (MOREOB, n.d.).

Institute for Healthcare Improvement

(www.ihi.org)

Idealized design of perinatal care White Paper (2005)

Cherouny PH, Federico FA, Haraden C, Leavitt Gullo S, Resar R. Idealized Design of Perinatal Care. IHI; 2005. http://www.ihi.org/resources/Pages/IHIWhitePapers/IdealizedDesignofPerinatalCareWhitePaper.aspx

ECRI Institute

ECRI Institute. Right On Time: Safe and Timely Delivery of Neonates. Presented at the: FTCA Risk Management Conference; August 7-8, 2012. Accessed March, 2021. https://www.youtube.com/watch?v=95v7osmALG4

References

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