Niger J Paed 2013; 40 (3): 206 - 210 ORIGINAL

West BA in a specialist Opara PI hospital in Port Harcourt, Nigeria

DOI:http://dx.doi.org/10.4314/njp.v40i3,1 Accepted: 7th December 2012 Abstract Objectives: To find the Sixty two (39.5%) of their mothers prevalence, and identify risk fac- had no antenatal care (ANC). ( ) West BA tors and outcome in neonates who Mode of delivery in 98 (62.4%) Department of Paediatrics, were admitted into the Braithe- was caesarian section, of which 80 University of Port Harcourt Teaching Hospital. Port Harcourt, Rivers State. waite Memorial Specialist Hospi- (81.6%) were emergencies, many E-mail: [email protected] tal (BMSH) for perinatal as- of whom had complications before Tel: +2348037078844 phyxia. presentation. One hundred and Method: This was a descriptive seven (68.2%) and 38(24.2%) ba- Opara PI cross sectional observational bies, had Apgar Score of 4-5 and 0 Department of Paediatrics, Braithewaite study of neonates with low Apgar -3 in one minute respectively. The Memorial Specialist Hospital, scores admitted over a period of commonest risk factors were Port Harcourt. Rivers State ten months into the Special Care cephalopelvic disproportion (CPD) Baby Unit of the BMSH. in the mothers and abnormal pres-

All babies with Apgar scores less entation, predominantly breech in than six at one minute and for the fetus. 31.6% of those with se- whom consent was obtained were vere perinatal asphyxia died. recruited consecutively. For out- Conclusion: Prevalence of perina- born babies with no Apgar score tal asphyxia is high. Lack of ANC, recording, a history of poor cry CPD and breech presentation were from birth with either poor colour, contributory factors. There is respiratory distress, floppiness or urgent need for maternal education loss of primitive reflexes were on need for ANC, early interven- used. tion and skilled care of babies at Results: One hundred and fifty birth. seven of 630 babies admitted had perinatal asphyxia giving a preva- Key words: perinatal asphyxia, lence of 29.4%. Mean gestational newborns, specialist hospital age of affected babies was 36.84±3.67 weeks, and mean birth weight was 3.0±0.9kg.

Introduction burden of long-term neurological disability and impair- ment. 3 Following improvements in primary and obstetric Perinatal asphyxia is a common neonatal problem and care in most industrialized countries, the incidence of contributes significantly to neonatal morbidity and mor- birth asphyxia has reduced significantly and less than tality. According to latest estimates by World Health 0.1% newborn infants die from perinatal asphyxia. 5 In Organization (WHO), of the 130 million infants born developing countries however, rates of perinatal as- globally each year, approximately 4 million babies die phyxia are still high, and case fatality rates may be 40% before they reach the age of one month 1. Ninety-eight or higher. 6-8 percent of these neonatal deaths take place in the devel- This story aims to explore the prevalence, recognize risk oping countries with perinatal asphyxia and birth inju- factors and outcome in neonates who were admitted into ries together contributing to almost 29% of these a specialist hospital for perinatal asphyxia. deaths 1. Most of the births in developing countries occur at home, usually attended by untrained birth attendants. Birth asphyxia or more encompassing, perinatal as- phyxia is estimated to be the fifth largest cause of under- Methodology five child deaths (8.5%), after pneumonia, diarrhoea, neonatal infections and complications of 2. This was a descriptive cross-sectional observational It accounts for an estimated 0.92 -1.2 million neonatal study of all newborns (0-28 days) with low Apgar scores deaths annually and is associated with another 1.1 mil- admitted between 1 st February to 30 th October, 2011 into lion intrapartum 3-4, as well as an unknown the Special Care Baby Unit (SCBU) of the Braithwaite 207 Memorial Specialist Hospital (BMSH) in Port Harcourt. 3.0 ± 0.9kg (0.7- 5.6kg) while the mean gestational age The BMSH is the specialist hospital of the Rivers State was 36.84 ± 3.67weeks (24 – 44weeks). Government, in Nigeria . It serves as a primary and terti- ary care centre for the state as well as a referral centre Apgar score recording of 4-5 at one minute (moderate for all the 23 Local Government areas of the state. It perinatal asphyxia) was observed in 107 (68.2%) neo- also offers free medical services for all children 0-5 nates, 38 (24.2%) had Apgar score 0-3 at one minute years and pregnant women. (severe perinatal asphyxia) while 12 (7.6%) did not have any Apgar score recording. Of 157 neonates with peri- The SCBU of the hospital comprises an inborn ward and natel asphyxia 142(90.4%) were inborn while 15(9.6%) an outborn ward. Babies whose mothers were booked in where outborn. There were 2255 live birth during the BMSH or in any of the health centers owned by the period of study giving a hospital base incidence rate of State Government and delivered in BMSH are admitted perinatal asphyzia in BMSH as 63.0 per 1000 live births. into the inborn wards. All other babies are admitted into Of 2255 babies delivered to 2252 mothers, 2249 the out born ward. (99.7%) babies were of singleton gestation while 6 (0.3%) of multiple gestation (3 sets of twin deliveries). All babies with low Apgar scores. less than six at one Of the 2252 deliveries during the study period, 1464 minute and whose parents/caregivers gave consent for (64.9%) were referred cases, of which 1389 (94.9%) had inclusion into the study were recruited consecutively obstetric complications. during the period of study. For outborn babies with no Apgar score recording, a history of poor cry from birth Ninety five (60.5%) mothers of babies with asphyxia with either of the following; poor colour, respiratory had antenatal care: BMSH and affiliated Government distress, floppiness and loss of primitive reflexes were Health Centres (80; 84.2%) and private hospitals (15; used. 9 The total number of live births for the hospital 15.8%) while 62 (39.5%) did not receive any form of within the period was obtained from the obstetric regis- antenatal care. Majority of the mothers of infants with ters in the labour room. perinatal asphyxia (140; 89.2%) were between the ages of 21-35 years. . Ninety eight (62.4%) were delivered by Other relevant data which were obtained included the caesarean section, 56 (35.7%) by spontaneous vaginal age, sex, birth weight, gestational age of recruited ba- delivery and 3 (1.9%) were instrumental deliveries. Of bies, parity, booking status, mode of delivery, place of the 98 infants delivered by caesarean section, 80 delivery, fetal presentations as well as problems during (81.6%) were by emergency caesarean sections. Perina- , labour and delivery in the mothers. The hos- tal asphyxia was observed most in infants with breech pital based incidence of perinatal asphyxia was calcu- presentation 79 (50.3%) followed by infants with lated using the number of babies with perinatal asphyxia cephalic presentation, 73 (46.9%) and face 5 (3.2%). born in the BMSH and total number of live births in the hospital during the period of study. Observed Risk Factors for Perinatal Asphyxia Data was arranged in frequency tables and analysed us- ing the statistical soft ware SPSS version 17.0 and There were 221 episodes of observed risk factors of Epi-info version 6.04. Analysis of variance was used to which 120 (54.3%) were maternal and 101 (45.7%) were compute means, ranges and standard deviations of con- fetal risk factors. The maternal, fetal and maternofetal tinuous variables. Data were presented as tables in sim- risk factors of perinatal asphyxia are shown in Table 1. ple proportion and comparison of subgroups carried out The commonest fetal risk factor observed in neonates with Chi-Square ( χ2) statistics. The statistical signifi- with perinatal asphyxia was abnormal presentation. Can cance at 95% confidence interval was p < 0.05. we rephrase this last sentence as: The commonest risk factor observed in neonates with perinatal asphyxia was abnormal presentation (fetal risk factor).

Results Characteristics of the Study Population

A total of 630 neonates (338 males and 292 females) were admitted into the SCBU, during the period, of which 157 had perinatal asphyxia, giving a prevalence rate of 24.9%. Of the 338 male neonates admitted into the SCBU, 88 (26.0%) had perinatal asphyxia while of 292 females admitted, 69 (23.6%) had perinatal asphyxia with a M:F ratio of 1.3:1. There was no signifi- cant difference in the incidence of perinatal asphyxia in both sexes (p value = 0.486).

The age on admission ranged between less than one hour and 192hours with a median age of 24.0 hours. The mean birth weight of babies with perinatal asphyxia was 208 Table 1 : Observed Risk Factors for Perinatal Asphyxia Risk Factors AS>3 AS<3 NO AS p-value Total=107 Total=38 Total=12 No % No % No % Maternal Factors Cephalopelvic disproportion 32 29.9 9 23.7 2 18.2 0.606 Hypertension 16 15.0 8 21.1 0 0.0 0.220 Prolonged Labour 13 12.1 7 18.5 3 27.3 0.286 Prolonged Rupture of membranes 9 8.4 4 10.5 1 9.1 0.897 Peripartum pyrexia 4 3.7 2 5.3 0 0.0 0.778 Diabetes mellitus 1 0.9 0 0.0 0 0.0 1.000 Fetal Abnormal presentation 54 50.5 24 63.2 6 50.0 0.409 Maternofetal Meconium stained liquor 8 7.5 6 15.8 0 0.0 0.229 Antepartum haemorrhage 4 3.7 2 5.3 0 0.0 0.778 Prolapsed/ compressed cord 3 2.8 0 0.0 0 0.0 0.653 Precipitate delivery 2 1.9 1 2.6 0 0.0 1.000 Clinical Features of neonates with Moderate and Severe Perinatal Asphyxia

The clinical features of infants with moderate and severe perinatal asphyxia are shown in Table II. Respiratory distress and depressed neonatal reflexes were the commonest clinical features observed in neonates with both moderate and severe perinatal asphyxia while loss of consciousness was the least. Abnormal tone, convulsion, poor suck and apnea were significantly observed more in infants with severe perinatal asphyxia than infants with moderate perinatal asphyxia.

Table 2: Clinical Features of Neonates with Moderate and Severe Perinatal Asphyxia

Clinical Features AS>3 AS<3 No AS p-value Total=107 Total=38 total=12 No % No % No % Respiratory distress 73 68.2 28 73.7 9 81.8 0.563 Depressed neonatal reflexes 53 49.5 19 50.0 6 54.5 1.000 Poor suck 11 10.3 8 21.1 6 54.5 0.001 9 8.4 9 27.7 4 36.4 0.006 Absent neonatal reflexes 9 8.4 8 21.1 2 18.2 0.108 Convulsion 4 3.7 5 13.2 5 45.5 0.000 Apnea 4 3.7 6 15.8 0 0.0 0.041 Lethargy 4 3.7 1 2.6 0 0.0 1.000 Irritability 2 1.9 1 2.6 0 0.0 1.000 1 0.9 2 5.3 3 27.3 0.001 Loss of consciousness 1 0.9 1 2.6 3 27.3 0.002

Thirty nine babies (24.8%) had features of Hypoxic ischeamic encephalopathy(HIE). Of these, 16 (15.0%) had AS >3, 16 (42.1%) had AS < 3 while 7 (58.3%) had no AS recorded. There was a statistically significant association between Apgar scores and severity of HIE (p=0.000). Outcome of Perinatal Asphyxia Discussion

Table 3 shows the outcome of neonates with moderate Perinatal asphyxia occurs worldwide and contributes and severe perinatal asphyxia. Of 107 neonates with significantly to neonatal morbidity and mortality with moderate perinatal asphyxia, 90 (84.1%) were very high incidence in developing countries. discharged and 14 (13.1%) died while of 38 neonates The incidence of perinatal asphyxia in this study is with severe perinatal asphyxia, 25 (65.8%) were dis- 63/1000 live birthsThis figure is very high when com- charged and 12 (31.6%) died ( χ2=6.74, p value = 0.034). pared with an incidence of 1-8/1000 live births observed in the US and other technically developed countries. 10 It Table 3: Outcome of Perinatal Asphyxia however compares favorably with figures in other cen- ters around the country and Africa. These figures remain Apgar score Discharged DAMA Died No (%) No (%) No (%) high when compared with a report by authors several years ago. 11 This was also noted in a study done in AS > 3 90 84.1 3 2.8 14 13.1 Ilesha, Nigeria, where authors compared the incidence AS ≤ 3 25 65.8 1 2.6 12 31.6 of birth asphyxia over two time periods ten years apart No AS 9 75.0 0 0 3 25.0 and concluded that the incidence and severity of birth Of the 39 neonates with HIE, 21(53.8%) were discharged, 17 asphyxia remained high despite changes in the social (43.6%) died while 1(2.6%) discharged against medical advice order. 12 This suggests that while there are improvements (DAMA) (p=0.000). in developed societies in terms of obstetric and neonatal 209 care, there is a slow change in the prevailing circum- Perinatal asphyxia was also observed most among ba- stances in developing countries. This has grave implica- bies who had breech presentation. Increased risk of peri- tions for achieving the Millennium Development Goals. natal asphyxia in babies with non-cephalic presentation has been reported in other studies. 16 Infants presenting Although in some studies, 5, 13-15 asphyxia was more breech have long been well known to encounter greater prevalent in males than females, similar to the study by hazards during the process of delivery with greater Nayeri et al, 16 there was no significant difference in incidence of birth asphyxia, birth trauma and death irre- incidence of perinatal asphyxia in this study in terms of spective of mode of delivery. 25-27 This may be because gender. fetuses presenting breech are more likely to have other associated problems like cord around the neck or even Birth asphyxia was common in good sized babies with a congenital anomalies which also predispose them to mean birth weight of 3kg . This trend has also been ob- perinatal asphyxia. served by other researchers 13 and has been attributable Other risk factors observed in this study included pro- to poor perinatal services in longed rupture of membranes, peripartum pyrexia, and maternity homes and hospitals. It is also pertinent to add haemorrhage. All of these have also been reported by that even where services are available, they may not be other authors. 17 utilized . Most of the clinical features of birth asphyxia seen in Over 90% of the babies with birth asphyxia were born in this study have been well documented. Of these, poor BMSH which is a specialist hospital. This finding con- suck, convulsion, abnormal tone and apnoea were noted trasts sharply with other findings which report a lower to be most commonly associated with increasing sever- incidence in babies delivered in specialist/tertiary ity of asphyxia. Respiratory distress was observed in hospitals. 17 However, as many as 39.5% of the mothers more than a third of newborns with both moderate and whose babies were asphyxiated did not receive any form severe birth asphyxia. This may be related to the under- of ANC, whilst some of those who received ANC did so lying hypoxemia and acidosis observed in such babies. 28 in less specialized hospitals. Over 90% of the mothers This study also showed a statistically significant rela- referred to the centre had complications of pregnancy or tionship between Apgar score and the occurrence of labour, thus increasing the risks of perinatal asphyxia. It hypoxic ischaemic encephalopathy. workers comparing can also be postulated as it is common in women in this the Apgar scoring system with umbilical artery pH in region that even those who receive ANC in specialized predicting neonatal death concluded that the Apgar centres may at time of delivery opt for other places only Score has remained as relevant as it was several years to return with complications. Lack of ANC has been ago, for the prediction of neonatal survival. 29 associated with increased incidence of birth asphyxia in several studies. 17,18 Case fatality rate was higher in severely asphyxiated infants. This supports findings by other workers which More than half of the babies were delivered by caesarian show a higher risk of death with very low Apgar scores. section, most of which were by emergency caesarian 29 This study showed an overall case fatality rate of sections (EMCS), many of them done during labour. 16.6% which was slightly lower than that in other This implies that there were already peri-partum Nigerian studies. The main difference being that some complications. High rates of EMCS have been reported studied only severely asphyxiated infants while our in other Nigerian studies. 19-21 Previous studies have study included babies with moderate asphyxia. shown that significantly more mothers of babies with birth asphyxia than of controls were delivered by emer- gency Caesarian section. 16, 22 There is an aversion to CS deliveries in our environment. 23- 24 Non-vaginal delivery Conclusion is generally viewed as a sign of maternal laziness, reproductive failure or a curse from perceived Prevalence of perinatal asphyxia is high. Lack of ANC, enemies. 25 It is therefore not uncommon that even CPD and breech presentation were contributory factors. women booked for elective caesarean sections often There is urgent need for maternal education on need for abscond, attempt vaginal delivery and only return when ANC, early intervention and skilled care of babies at an emergency CS is inevitable. This aversion to caesar- birth. ian deliveries, inevitably increases the risk of perinatal asphyxia and buttresses the fact that a properly trained person in neonatal resuscitation preferably a Paediatri- Authors’ contributions cian should be present at every delivery especially the high risk ones. Presence of working resuscitation equip- West BA: Conception, design and data analysis ment e.g. suction, proper size ambu bags, endotracheal Opara PI: literature review and drafting of the manu tubes, neonatal laryngoscopes and oxygen supply should script be made mandatory. The availability of these facilities Conflict of Interest: None were not explored in the study. Funding: None

210 References

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