RISK FACTORS CONTRIBUTING TO THE DEVELOPMENT OF FETAL BIRTH TRAUMA

Full Text

Relevance. Birth trauma is considered to be a mechanical effect on the fetus during childbirth and is the cause of violation of the integrity of organs or tissues during childbirth [1]. Intranatal damage to the fetus can occur during violent contractions with combined obstetric pathology, predisposing to the formation of traumatic injuries. Predisposing factors are also complications such as fetal hypoxia, impaired nutrition and development, the occurrence of intrauterine infections, and prematurity. Under such conditions, during childbirth, the possibility of developing BT increases, even in situations where there is no doubt about the physiologically proceeding act of childbirth. In the structure of BT, the so-called "obstetric trauma" that occurs with obstetric benefits is singled out [2, 3]. The severity of intranatal injuries is different: bone fractures, violation of tissue integrity, local circulatory disorders, such as hemorrhage, edema, stasis, thrombosis in the area of mechanical impact. The term birth trauma includes rupture of tissue and organs during childbirth. The following types of fetal BT are distinguished: BT of the skeleton, soft tissues and abdominal organs (extremely rare situations - rupture of the liver, spleen). BT includes injuries that form antenatally, that is, due to hypoxic damage to organs [4, 5]. The division of BT into mechanical and hypoxic is conditional.
The problem of birth injuries of a newborn is dealt with by various specialists, including obstetricians-gynecologists, neonatologists, pediatricians, and forensic doctors [6, 7]. There is an obvious or apparent possibility to manage this perinatal pathology [7, 8]. Also, the risk of developing intranatal damage remains one of the main indicators for increasing indications for abdominal delivery. At the same time, reducing morbidity and mortality among newborns remains the most important medical and social task. To prevent the possible development of intranatal damage, perinatal risk must be determined continuously during the course of pregnancy and childbirth. The formation of birth injuries of the fetus is affected by the frequency of complications of pregnancy, childbirth, and extragenital diseases [9]. The selection and monitoring of high-risk groups will improve obstetric and perinatal care for each group of women and their newborns.
The purpose of the study is to identify possible risk factors that affect the formation of a birth injury to the fetus.

Materials and methods. 190 observations were analyzed, which included 95 cases of fetal birth trauma that occurred in the city of Omsk (main group) over the past ten years. In newborns after birth and their examination, the following pathology was diagnosed: P11.5 - damage to the spine and spinal cord, P12.0 - cephalohematoma due to birth trauma, P12.2 - subaponeurotic hemorrhage, P12.3 - hematoma of the scalp, P13.4 - fracture of the clavicle, P14.0 - Erb's palsy, P 14.1 - Klumpke's palsy. For the comparison group, a sample was made of 95 birth histories without birth injuries. To analyze the course of gestation and childbirth, the medical records of pregnant women, women in labor and childbirth, the history of childbirth and extracts from the histories of the development of newborns were used. The material was processed statistically using the Microsoft Office Excel software package. The evaluation of the values of the results was made using the Student's t-test and the matching criteria, the analysis of the four-field table, the chi-square test.
Results. When studying the risk factors for BT complicating the course of pregnancy, it was found that the most common factors contributing to intranatal damage were complications associated with gestational age, primarily prematurity. In the main group, prematurity was observed in 15.2% of cases, overmaturity - in 7.6%; (p = 0.031) In case of prematurity, birth traumatism is promoted by the immaturity of the musculoskeletal system of the fetus, while there is a high risk of intracranial hemorrhages, in case of overmaturity, the high density of the skull bones and their poor configuration, as well as chronic hypoxia, contribute to a decrease in the adaptive capabilities of the body, traumatic In the group with damage to infants, the following risk factors were noted: fetoplacental insufficiency - in 22 women in labor (20.9%), in the group without BT - in 6 (5.7%; p = 0.002). In 4%) cases, neonatal asphyxia was detected, intrauterine growth retardation - in 2.9%; in the group of infants without BT - 2.9% (p=0.009) and 1.9% (p=0.651).
Preeclampsia complicated pregnancy and childbirth in 13.3% of mothers who gave birth to children with BT; in women who gave birth to children without BT, preeclampsia was detected in 7.6% (p=0.027). Also, a frequent risk factor that contributes to intranatal damage is somatic diseases of the pregnant woman, which occurred in 22 women of the main group (20.9%) and in 9 (8.6%) women of the comparison group (p = 0.011). Extragenital diseases included arterial hypertension, kidney disease, gestational diabetes, and thyroid disease. Chronic iron deficiency anemia was detected in 14 (13.3%) pregnant women in the main group and in 10 (9.5%; p=0.383) in the comparison group. A large number of congenital infections diagnosed during the period of observation of pregnant women were in the main group: in 36 pregnant women (34.2%) and in 7 (6.7%) in the comparison group (p<0.001). Intrauterine infection was clinically manifested by relapses of threatened abortion in 12 pregnant women (11.4% of cases) in the main group and in 2 (1.9%; p=0.006) in the compared group. Signs of intrauterine infection were accompanied by confirmation of most often viral infections (influenza, covid-19, herpes virus infection, cytomegalovirus infection, and others). At the same time, changes in the quality (determination of suspension during echographic scanning) and the volume of amniotic fluid (polyhydramnios, oligohydramnios) were found in 7 (6.7%) and 2 (1.9%; p=0.031) pregnant women, respectively, in the studied groups.
In 5 (4.8%) women whose children received BT during childbirth, a narrow pelvis was diagnosed. Anatomically narrow pelvis was not detected among women in the comparison group (p=0.013). Such a low percentage of this complication is due to the fact that in modern obstetrics, when diagnosing anatomical changes in the pelvis, especially in combination with other complications of pregnancy, abdominal delivery is more often performed. In 6 (5.7%) observations of the main group, a large fetus was identified, in the comparison group, a large fetus was detected in 2 women (1.9%; p=0.055). During childbirth with a fetus weighing more than 4000 g, fractures of the clavicles and Erb's paralysis are more often observed, shoulder dystocia contributed to traumatic injury, which is a manifestation of a clinically narrow pelvis [1]. Anomalies in the position of the fetus occurred in 6 (5.7%) women in labor in the main group and in one woman in labor in the comparison group (0.95%) (p=0.055). Breech presentation of the fetus was observed almost equally in the studied groups: in 3 (2.9%) women of the main and in one (0.95%; p=0.313) comparison group. The low percentage of these complications is due to the fact that in modern conditions, when diagnosing anomalies in the position of the fetus, a caesarean section is more often performed.
Frequent complications of childbirth, among the factors contributing to damage to the fetus, were premature rupture of the fetal bladder, a long anhydrous period, anomalies of the birth forces, a violation of the structure and location of provisional organs. Complications of childbirth, in some cases, some inadequacy of obstetric tactics can lead to increased morbidity in newborns and perinatal mortality. In intranatal fetal injury, the importance of prenatal rupture of amniotic fluid was revealed in 39 pregnant women (37.1%) in the main group and in 8 (7.6%; p<0.001) in the comparison group; at the same time, a long anhydrous interval was diagnosed in 17 (16.2%) and 5 (4.8%; p=0.007) women in labor, respectively, in the studied groups. Labor anomalies complicated labor in 15 (14.3%) women who gave birth to children with RT, and in 4 (3.8%) women in labor without RT of newborns (p = 0.008). In women with weakness of labor forces, labor stimulation was performed with oxytocin: 10 (9.5%) and 6 (5.7%; p=0.297) women, respectively, of the studied groups. Incorrect positions and insertion of the fetal head were diagnosed in 6 (5.7%) women of the main group, in the other group such cases were not noted (p = 0.013).
Disturbances in the form of entanglement of the umbilical cord in the neck and trunk of the fetus with compression, true knots of the umbilical cord were found in 32 (30.4%) and 5 (4.8%; p<0.001) cases of the studied groups. Placental abruption was determined in 15 (14.3%) and 3 (2.9%; p=0.003) cases of the studied groups, respectively.
In the course of the study, the influence of the use of obstetric aids and childbirth operations on the formation of birth trauma was studied. Benefits provided by obstetricians and obstetricians-gynecologists and delivery operations were performed in 23 (21.9%) and 5 (4.8%; p<0.001) women of the study groups. The allowance according to Tsovyanov was made by 5 (4.8%) and 3 (2.9%) women in labor of the research groups (p=0.470). Abdominal delivery was performed in 15 (14.3%) women of the main group and in 5 (4.8%) cases of the comparison group (p=0.019). All operations were carried out on an emergency basis. Episiotomy was performed in 8 (7.6%) and 2 (1.9%) cases of the study groups (p=0.052).

Discussion. The results of the study do not negate the significance of the mechanical impact that contributes to intrapartum injuries, including the discrepancy between the size of the bone pelvis and the fetal head. Fetal injuries are promoted by somatic diseases and obstetric complications, which are identified in the main group more often than in the comparison group, similar results were presented by other researchers [2-4]. The results of the study showed that the risk of perinatal complications should be taken into account during the monitoring of pregnant women in the antenatal clinic in dynamics, as well as during childbirth, especially in combination with new obstetric complications. The use of various prognostic tables makes it possible to form pregnant women into groups of increased perinatal risk, to predict pathological conditions in parturient women and to determine the degree of intranatal risk.
Conclusion. Birth trauma is an important problem in obstetrics, despite the preventive measures taken during pregnancy and when choosing obstetric tactics during childbirth. Risk factors that damage the fetus during childbirth are obstetric complications (prematurity, overmaturity, feto-placental insufficiency, fetal hypoxia, incorrect insertion of the fetal head, macrosomia, narrow pelvis), complications in childbirth (prolonged anhydrous interval, premature rupture of the membranes) , defective development of the placenta and umbilical cord, intrauterine infections, entanglement of the umbilical cord around the neck of the fetus with compression. Also, a factor contributing to the formation of birth defects is the presence of somatic diseases.

 

About the authors

Ekaterina M. Ushenina

Omsk State Medical University of the Ministry of Health of the Russian Federation

Author for correspondence.
Email: katya_ush00@mail.ru
ORCID iD: 0000-0002-3351-3318
Russian Federation, 12 Lenin str., Omsk, 644099, Russia

Alina N. Sapronova

Omsk State Medical University of the Ministry of Health of the Russian Federation

Email: alina.sapronova@mail.ru
ORCID iD: 0000-0002-0682-9691
Russian Federation, 12 Lenin str., Omsk, 644099, Russia

Ekaterina V. Lisitsa

Omsk State Medical University of the Ministry of Health of the Russian Federation

Email: kate.lisitsaa@mail.ru
ORCID iD: 0000-0003-4199-4171
Russian Federation, 12 Lenin str., Omsk, 644099, Russia

References