Introduction

Injuries sustained at birth has been given different names such as birth trauma and obstetrical injuries and they are associated with different etiological causes.₁,₂ The important causes of these injuries has been associated with various etiological factors which are macrosomia , breech presentation, shoulder dystocia, and forceps-assisted deliveries have all been implicated.₃ The incidence of major trauma was 3.16% in Finland.₁ The injuries include fractures of long and short bones ₄ ,₅ and even depressed skull and orbital fracture₆, neural injuries, like Erb's palsy , facial nerve injury₇ other include laceration and even castration!₈ The commoner injuries are fracture of the clavicle and Erb's palsy .₁,₆ Early detection and prompt management is important in the these pathologies. The study was conceived to know why when most of the injuries were seen in babies of low socio economic mothers and to advice accordingly.

Methods

This is a retrospective study. The clinical notes of patients with orthopaedic birth injuries between March 2002 and November 2004 at the Wesley Guild Hospital, Ilesa, Nigeria were analysed. The analysis was done on the basis of time of presentation, sex, age, aetiology, ante natal history of the pregnancies, and mothers' educational background and parity , treatment and outcome of management of the birth injuries. Clinical notes with doubtful records and documentation were excluded from the study.

Result

In this study, 11 patients in 11 deliveries with orthopaedic birth injuries were seen and males were 7 while the females were 4, the Male: Female ratio was 1.75:1. There were 382 live births within the period of study. The injuries included 6 fractures, comprising 5 femoral shaft fractures and 1 humeral shaft fracture; and 5 Erb's palsy. The problems were picked up between 1 to 25 days of delivery with mean of 7.55 ± 7.62 days. Deliveries were at different places including farm! Church=3, private nursing/hospitals =3 and 4 at the study center (a University teaching hospital)

Figure 1

Table 1: Types of birth injuries and method of delivery

The mean age of the mothers was 28.36± 7.4 years and their parity was between1 to 6 and with mean of 3.55± 1.44. The pregnancies were termed but no ante natal care in eight mothers. The eight mothers were primary and secondary school drop- outs who were engaged in petty trading for survival. The weight of the babies ranged between 1.75 kg to 4.2 kg with mean of 2.9 ± 0.81 kg.

The fracture were treated with simple back slap Plaster of Paris and all healed satisfactorily within 6 weeks but the Erb's palsies were treated with physiotherapy by the mother and the physiotherapist. Recovery was slow and at 6 months post injury full recovery has not occurred.

Discussion

In this study, fractures accounted for the major othopaedic injuries of which femoral fractures were 5 and there was 1 humeral fracture, this is different from other studies where clavicular fracture has been noted to be commonest birth injury.₁,₆ Nine of the deliveries were assisted deliveries resulting into 4 fractures and 5 Erb's palsies. Traumatizing maneuvers during the deliveries would have accounted for these pathologies in the assisted deliveries thus supporting previous study by Camus et al. ₄ It was found that diagnosis and presentation of those with fractures were within 2 days while those with Erb's palsy presented late with mean of 7.55 ± 7.62 days. A patient actually presented on the 25^th day of delivery even though the mother was aware that there was problem with the upper limb involved. The difference in time of presentations might be because the fracture was painful and the neural injury was painless. The mothers of the patients with neural injuries brought the patients to the hospital late because they thought that the anomaly is self-limiting and recovery will eventually occurred. Four of the patents were products of multiple pregnancies (the injuries were not influence by whether the patient was first or second twin), 3 of which had femoral shaft fracture and the other Erb's palsy, 3 of these products of multiple pregnancies were of low birth weight .

In this study birth injuries were associated with multiple pregnancies and low birth weight as reported in other places. ₅, ₉ Eight of the mothers were primary and secondary school drop outs, and petty traders with very low income. They had no ante natal care before delivery. One of the deliveries of those poor pregnant women was in the farm! and the baby had femoral shaft fracture. The low level of education and poverty would have accounted for inability to receive ante natal care and would have led to deliveries at poorly equipped centers and poor delivery techniques which would have cause the birth injuries. All fractures were treated and satisfactory early fracture healing was achieved within 6 weeks this agrees with reports from other places .₉,₁₀ It has been suggested that patients with fracture of the clavicles should be thoroughly evaluated to rule out damage to brachial plexus as well.₄ In this study non of the five patients with Erb's palsy had clavicular fracture. The poor outcome of the Erb's palsies might not be unconnected the late presentation of the patients.

Lack of antenatal care has been identified as one of the risk factors to development of birth injury ₁₁. In this study the eight of the pregnancies lacked antenatal care and this could be due poverty, poor level of education and ignorance on the importance of ante natal care.

Early identification of obstetric factors and improvement in obstetric care of both the mothers and babies during delivery and stoppage of traumatising manoeuvres particularly in the hands of the inexperienced would reduce the incidence and severity of this disability. Educating the pregnant women about the importance of antenatal care will play important part in the reduction of this pathology. It will be important to examine the neonates thoroughly after deliveries to detect birth injuries and manage promptly.

There should be provision of accessible and affordable quality obstetrics services all over the federation. Also vulnerable cases should be identified early and referral made to appropriate level of pregnancy care

Correspondence to

Johnson Dare Ogunlusi Consultant Accident and Emergency / Orthopaedic Surgeon & Traumatologist, Victoria Hospital, Castries. St Lucia. West Indies. E mail: gbemidare@yahoo.com