Are Current Measures of Neonatal Birth Trauma Valid Indicators of Quality of Care?

P Kumar; L-A Papile; K Watterberg

Disclosures

J Perinatol. 2015;35(11):903-906. 

In This Article

Limitations of Birth Injury Rate as an Indicator of Quality of Care

Birth Traumas Lack a Consistent Definition

Birth injury and birth trauma have been used interchangeably in the literature and variable definitions of neonatal birth trauma have been used by different authors. Although it is clear that traumas secondary to mechanical forces, resulting in well-defined structural injuries such as lacerations, fractures and hemorrhages are birth traumas, there is less clarity regarding whether or not organ dysfunction secondary to hypoxic–ischemic injury should also be classified as a birth trauma. Although it can be argued that hypoxic–ischemic encephalopathy is one of the most important birth traumas, it is not included in current definitions of birth trauma. In addition, some birth traumas may be the result of a calculated risk taken by obstetric providers to expedite delivery to reduce the likelihood of hypoxic–ischemic multi-organ injury and thus, efforts by physicians and institutions to reduce the reportable rates of neonatal birth traumas could have unintended consequences, such as an increase in the number of infants with hypoxic–ischemic multi-organ injury, an increase in cesarean deliveries or other untoward events.

It is also not clear if all abnormal neonatal physical findings should be considered birth traumas. For example, some studies have included caput, chignon, cephalohematoma and skin bruising as birth traumas, whereas others would consider these a part of the normal birthing process.

Not all Birth Traumas are Clinically Apparent at Birth

Not all birth traumas are clinically apparent during the initial hospital stay, and thus may not be recorded. For example, internal hemorrhages can only be diagnosed by imaging studies. Because some infants with internal bleeding may appear well, the reported rate of this injury will underestimate the true rate. The diagnosis of some birth traumas requires a high index of suspicion and a skilled practitioner, as well as the availability of hospital-based resources such as neuroimaging modalities and radiologists trained to read neonatal neuroimaging studies. These differences by themselves may account for some of the variability in reported birth trauma rates at different institutions.

Not all Birth Traumas are Preventable

Reduction in the rate of neonatal birth trauma has been an important component of several recent perinatal safety initiatives.[12,17–20] Some have reported that implementation of a bundle of practices led to a significant reduction in birth traumas, and proposed a goal of zero birth traumas.[12,18,20] However, reports of the in utero origin of several neonatal morbidities such as brachial nerve palsy and intracranial hemorrhage (ICH), as well as the presence of birth injuries in infants born by spontaneous vaginal delivery, raise the question of whether a target of zero birth traumas is appropriate.[21–23] Recent prospective studies suggest that as many as half of all vaginally delivered asymptomatic term infants have evidence of an ICH on brain MRI.[22,24] One study found that mothers of neonates with ICH were not more likely to have had assisted vaginal delivery or other signs of a difficult delivery such as perineal lacerations, and none of the neonates had evidence of other birth traumas.[22] Thus, it is unclear what an acceptable baseline rate of birth trauma should be. Based on the reported rates of findings consistent with birth trauma in 'normal deliveries', Sauber-Schatz[2] proposed an acceptable 'normal' baseline rate of 18 birth injuries per 1000 in-hospital births, but any absolute number is likely to vary between institutions and needs validation.

Not all Birth Traumas are the Same

Birth traumas vary considerably in severity and extent, as well as long-term consequences. The utility of birth trauma rates is very limited if no additional information regarding severity or long-term outcome is incorporated in the data. For example, a birth injury rate of 5/1000 live births due to scalpel skin wounds is very different from a birth injury rate of 5/1000 live births owing to subgaleal hemorrhages or brachial plexus injuries.

Other Limitations

The current definition of birth trauma excludes some common and important birth injuries, such as clavicular fractures and brachial plexus injuries. Furthermore, some inclusions and exclusions to the definition appear inconsistent and arbitrary. For example, Erb's palsy and Klumpke's palsy are excluded, whereas phrenic nerve palsy is included, yet these frequently have the same underlying etiology—a brachial plexus injury. In addition, the current definitions only include term infants and those discharged from the birth hospital. (Supplementary Appendix A http://www.nature.com/jp/journal/v35/n11/suppinfo/jp201571s1.html) This approach misses important groups of infants, such as preterm infants, infants who were transferred to another institution, or those who died during their initial hospital stay. Further, some criteria in the current definitions, such as 'subdural and cerebral hemorrhage due to birth trauma or intrapartum anoxia or hypoxia' and 'massive epicranial subaponeurotic hemorrhage,' are subjective and can be difficult both to identify and to attribute to birth trauma based on administrative data alone. Several studies from different health-care settings have shown that the accuracy of administrative data is prone to subjectivity, variability and error, and diagnoses retrieved from electronic administrative sources and manual chart review frequently disagree.[25–27] Thus, the determination of birth trauma rate and severity using administrative databases may not be accurate.

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