By Ikobho, EH; Atemie, G; Addah, A (2024). Greener Journal of Medical Sciences, 14(2): 77-88.
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Vol. 14(2), pp. 77-88, 2024
ISSN: 2276-7797
Copyright ©2024, the copyright of this article is retained by the author(s)
https://gjournals.org/GJMS
1* Associate Professor, Department of Obstetrics and Gynecology, Niger Delta University Teaching Hospital, Yenagoa, Bayelsa State, Nigeria.
2 Department of Obstetrics and Gynecology, Federal Medical Center, Yenagoa, Bayelsa State, Nigeria.
3 Department of Obstetrics and Gynaecology, Niger Delta University Teaching Hospital.
Type: Research
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Published: 05/06/2024
Dr Ikobho Ebenezer Howell
E-mail: ikobhoebenezer12@ gmail.com
Phone: +2348037055273
Background: Birth asphyxia following delivery by emergency caesarean section is quite common, and it’s highly associated with perinatal morbidity and mortality.
Objectives: To determine the effects of obstetric factors on birth asphyxia following emergency caesarean section. It would also determine the extent to which delay in carrying out caesarean section impacts on birth asphyxia, with respect to hospital, laboratory and patient related logistic factors.
Method and materials: This was a retrospective cross-sectional study of 184 women delivered by emergency caesarean section. Data was collected in the labour ward, labour ward theatre, and antenatal ward. Information relevant to this study obtained include: patients bio-data, and obstetrics factors such as booking status, duration of labour, the indication for caesarean section, source of referral, and whether surgery was elective or emergency.
Data on factors that could delay onset of caesarean section were absence of electricity and water supply, delay in providing cross-matched blood, and laboratory investigation results necessary for surgery. Patient related factors were refusal to sign informed consent on time, and delay in providing materials needed for surgery, Theatre related factors were unavailability of theatre space, presence of competent anesthetist or surgeon at the time of surgery, and the type of anesthesia administered (general or spinal).
Fetal information was: birth asphyxia based on 5 minutes APGAR score, admission to neonatal unit, and perinatal mortality from birth asphyxia.
Results: Out of 184 babies delivered in this study, 32 had birth asphyxia, giving a rate of 17.4%. The perinatal mortality rate from birth asphyxia was 54.3/1000 births, and prolonged obstructed labour was responsible for 50% of the mortalities.
Obstetrics factors that significantly increase the rate of birth asphyxia were: unbooked patient odds ratio = 1.79[0.98, 3.26] p = 0, 05, and women referred by traditional birth attendants, odds ratio = 2.67[1.11, 6.43] p = 0. 02
Hospital logistic factors that significantly increase the rate of birth asphyxia by delaying the onset of emergency caesarean section were: poor electricity supply, odds ratio = 2.48[0.97, 6.32], p = 0.05, lack of sterile surgical packs, odds ratio = 4.59[0.75, 27.99] and delay in obtaining laboratory results, odds ratio = 3.06[0.48, 11.13]. Others were delay in giving consent for surgery, odds ratio = 2.47[0.77, 7.97], and the use of general anesthesia, odds ratio = 2.85[0.65, 12. 56].
On multiple logistic regression, the most significant predictor variables for birth asphyxia were booking status r2 (%) = 6.6, p = 0.00, source of referral for caesarean section, r2 (%) = 4.8, p = 0.03, and educational level r2 (%) = 2.4, p = 0.03.
Conclusion: During emergency caesarean section, obstetrics factors are undoubtedly central to the pathogenesis of birth asphyxia. However, this study has brought to limelight the significant role played by hospital logistic factors that delay the onset of surgery. Eradicating these factors in our hospital settings could save the lives of our babies.
During pregnancy and child birth, complications that necessitate emergency caesarean section are quite common. Some of the most frequent in West Africa are: cephalopelvic disproportion (CPD), severe preeclampsia and eclampsia, prolonged obstructed labour, fatal distress, abnormal lie and footling breech. Others are severe antepartum hemorrhage, and less frequently, intrapartum hemorrhage. [1, 2]
Some of these complications, especially the hypertensive disorders, exhibit inherent ability to cause fetal distress via compromise in utero-placental blood flow. [3] However, experience from obstetrics units in West Africa indicates that many cases of emergency caesarean are unduly delayed, and this could worsen the existing complications, which could lead to fetal distress.
A very common source of delay in Nigeria is late referral to hospital, especially by traditional birth attendants [4], and health centers, when serious complications have set in. [4, 5] An audit of childbirth emergency referrals by trained TBAs in Enugu, Southeast Nigeria revealed a delay of over 12 hours in 75% of cases, before referral to hospital. [5]
Within the hospital setting, delay in instituting appropriate and timely emergency obstetrics care is referred to as third party delay. [6, 7] In West Africa, this is quite common, and sources of delay identified in Nigeria include: hospital logistic problems like poor electricity and water supply. Common laboratory sources are delay in obtaining results mandatory for surgery, and delay in providing cross matched blood. [8, 9] Some patients significantly delay their surgeries by refusing to sign informed consent on time.
Studies in Ibadan and Port Harcourt reported hospital logistic problems as the cause of delay in carrying out emergency caesarean section in 43.6 %, and 18.8% of the cases respectively[8, 9] There is overwhelming evidence that undue delay correlates positively with low APGAR score, fetal distress and poor fetal outcome. [10, 11] A fetus that is in distress during labour usually manifests at delivery as birth asphyxia.
Birth asphyxia is defined as the inability of the newborn to initiate and sustain enough respiration after delivery and is characterized by marked impairment of gas exchange [12]. The diagnosis is usually made when the APGAR score is < 7 at 5 minutes, and if the pH of the umbilical cord arterial blood is <7. [12, 13]
Based on APGAR score, the severity of birth asphyxia is categorized as sever (0 – 3), moderate (4 – 6), and normal (7- 10). [14] Birth or perinatal asphyxia is not common in developed countries because of advances in emergency obstetrics services. [15] However, in poor resource settings, the prevalence is quite high. In Port Harcourt, Nigeria, it was 29.4%, [16] and 18% in Ethiopia. [17] However a much lower rate of 5.3% was reported in Uganda. [18]
The danger of perinatal asphyxia relies on its potential to cause severe hypoxia, with neurological impairment, multisystem organ dysfunction, and perinatal mortality. [12, 13] Hospital based studies in northern Nigeria reported high mortality rates from birth asphyxia; 14.7% in Nasarawa, [19] and 25.5% in Gusua. [20] Impairment of neurological function as a complication, manifested as seizure disorder in 11.9% in Benin City, in Nigeria. [21]
Though birth or perinatal asphyxia has been widely studied globally, including our environment, most studies focus attention only on the effect of obstetrics factors on perinatal outcome. There has been no study on the effects of hospital logistic factors, hence the need for this study.
This study intends to determine the effects of obstetric factors on birth asphyxia following emergency caesarean section.
It would also determine the extent to which delay in carrying out caesarean section impacts on birth asphyxia, with respect to hospital, laboratory and patient related logistic factors. Finally, it would determine the socio-demographic characteristics of the subjects, and fetal outcome.
This study was carried out at the labour ward, labour ward theatre, and antenatal ward, department of obstetrics and gynaecology, Niger Delta University Teaching Hospital (NDUTH). Being a teaching hospital, it serves as a referral centre for the entire Bayelsa State, and some parts of the neighboring states, such as Delta, Abia and Rivers State.
This was a cross-sectional study of 184 women delivered by emergency caesarean section. It was carried out from January 2022 to January 2024.
Included in this study were both booked and unbooked parturients who developed complications during pregnancy, and were delivered by emergency caesarean section.
Excluded from this study were pregnant women who had spontaneous vaginal delivery, and instrumental vaginal delivery. Also excluded were pregnant women who developed antenatal complications and were delivered by elective caesarean section, and women diagnosed with intrauterine fetal death.
This encompasses all pregnant women delivered by emergency caesarean section in NDUTH during the study period, who fulfilled the inclusion criteria; a total of 184 was obtained.
Data was collected in the labour ward, labour ward theatre, and antenatal ward. Information relevant to this study obtained include: patients bio-data, and obstetrics factors such as booking status, duration of labour, the indication for caesarean section, source of referral to NDUTH, and whether surgery was elective or emergency.
Due to the fact that delay in timely conduct of emergency caesarean section could adversely affect the new born via asphyxia, data related to delaying factors within the hospital setting was collected. Hospital related factors include: absence of electricity and water supply, delay in providing cross-matched blood, and laboratory investigation results necessary for surgery.
Patient related factors that caused delay were: refusal to sign informed consent on time, and delay in providing materials needed for surgery, either due to lack of fund or patient unaccompanied by relatives.
Theatre related delaying factors were unavailability of theatre space, presence of competent anesthetist or surgeon at the time of surgery, and the type of anesthesia administered (general or spinal).
Though the internationally accepted decision-to-delivery interval (DDI) for emergency caesarean section is 30 minutes, it’s extremely difficult to achieve this target in Nigeria because of the complex logistic problems. A study on DDI in Nigeria reported a mean interval of 119.2 ± 95.0 minutes in Ibadan, [8] and 60 – 120 minutes in Port Harcourt. [9] There is no policy or guideline on DDI in NDUTH. However, for the purpose of this study, we assumed DDI above 90 minutes as delayed. This is a retrospective study, and we relied on the information documented in the case notes of the patients, for data collection.
APGAR score was assessed in theatre by the neonatologist immediately after delivery of the baby. It was assessed at 1 minute, and at 5 minutes. In this study, the score at 5 minutes was used, as it’s the bases for diagnosis of birth asphyxia, in line with international best practice. [12] In line with international practice, we categorized APGAR score of 7 – 10 as normal, 4 – 6 as moderate, and 0 – 3 as severe birth asphyxia. We used the total number of babies diagnosed with moderate and severe birth asphyxia for this study.
In this study, perinatal mortality was limited to only babies that died as a result of birth asphyxia, and its complications. Fetal death at birth was diagnosed by the pediatricians in theatre, when there was no sign of life after resuscitation for a period of 20 minutes. Also included in our records were babies, who were severely asphyxiated and admitted, but died within the first week after birth.
Data was coded into SPSS statistical package version 25 spreadsheet, and Epi Info statistical software version 7, and analyzed. Results were presented in tables as rates, proportions, and mean with standard deviation. Test of significance was by odds ratio, the degree of association was by Pearson’s correlation coefficient, and predictor variables with simple and multiple linear regression. At 95% confidence interval, the p value was set at ≤ 0.05.
Permit to proceed with this study was granted by the ethical committee of NDUTH, with registration number NDUTH/REC/0032/2024.
Table 1: Birth Asphyxia, Admission for Neonatal Care, And Perinatal Mortality
(N = 184)
(N = 100)
Total number of babies admitted
The mean APGAR score at 1 minute was 6.22 ± 2.57, and at 5 minutes, it was 7.69 ± 2.63. Out of a total of 184 women delivered by emergency caesarean section in this study, 62 babies (33. 6%) were diagnosed with birth asphyxia (moderate and severe asphyxia) based on 1 minute APGAR score. However, with resuscitation at 5 minutes, the rate reduced to 32 (17.4%). The neonatal admission rate for birth asphyxia was 11.4%.
Ten (10) babies died within 7 days, giving the perinatal mortality rate (from birth asphyxia) of 5.5%, or 54.3/1000 births.
Table 2: Socio-Demographic Characteristics of the Women, Birth Asphyxia and Perinatal Mortality
of subjects
N = 184
N = 100%
(moderate and severe)
N = 32
N = 17.4%
N = 10
N = 5.4%
5
The mean maternal age was 30.3 ± 5.7 years, the median parity was para 1, and most (45.5%) attained secondary level of education. Majority of the women 173(94.0%) were married, and predominantly from Ijaw tribe in the Niger Delta region in Nigeria.
Table 3: Obstetrics and Hospital Logistic Factors, and Birth Asphyxia
ratio
value
10(5.4%)
2.85 [0.65,12.56]
Spinal anesthesia
The mean duration of labour was 19.3 ± 17.4 hours
The rate of birth asphyxia was significantly higher in women who did not receive antenatal care (unbooked patients) odds ratio = 1.79[0.98, 3.26] p = 0, 05, and women referred in labour by TBA, odds ratio = 2.67[1.11, 6.43] p = 0. 02.
Though CPD was the commonest indication for emergency caesarean section in NDUTH 49(26.6%), prolonged obstructed labour was the commonest cause of fetal distress, accounting for 10(5.4%) of the cases, and it was responsible for half (5out of the 10) of the perinatal mortalities..
With respect to factors that caused delay in timely surgical intervention following decision to carry out caesarean section in NDUTH, hospital logistic factors predominates. Poor electricity supply significantly increased the rate of birth asphyxia, odds ratio = 2.48[0.97, 6.32], p = 0.05.
The chances of fetal distress was increase by 4 fold by unavailability of surgical instrument packs, odds ratio = 4.59[0.75, 27.99], and 3 fold by delay in obtaining necessary laboratory results, odds ratio = 3.06[0.48, 11.13].
Delay from theatre and patient related factors had little influence on the rate of birth asphyxia in NDUTH, as most of the indices were not significant. However, delay in giving consent increases the chances by 2 folds, odds ratio = 2.47[0.77, 7.97], so also is the use of general anesthesia, odds ratio = 2.85[0.65, 12. 56].
Table 4: Pearson’s Correlation Coefficient between the Factors Variables, Birth Asphyxia and Perinatal Mortality
The most significant correlates for birth asphyxia were booking status (- 0.256), source of referral (0.219), and educational level (0.155). For fetal demise, the most important correlate was indication for caesarean section (0.132), however it was not significant.
Table 5: Simple Linear Regression of the Predictor Variables for Birth Asphyxia
The most significant predictors for birth asphyxia in NDUTH are patient’s booking status r2 (%) = 6.6, p = 0.00. Followed by the source of referral for caesarean section, r2 (%) = 4.8, p = 0.03, and the educational level r2 (%) = 2.4, p = 0.03.
Table 6: Multiple (Stepwise) Linear Regression of the Predictor Variables For Birth Asphyxia
With all the significant predictor variables combined, the r2 (%) = 11.4%. This implies that my regression model could only explain 11.4% of the emergency caesarean sections that were complicated with moderate to severe birth asphyxia.
Birth asphyxia following delivery is very common in West Africa, especially in Nigeria, largely due to poorly developed health infrastructures, and emergency obstetrics services. [16, 17] This is further compounded by poor implementation of health policies, tribalism and lack of political will. It’s common practice for health faculties to be located in odd areas, such as home towns and villages of politicians, with very poor utilization.
Nigeria being a poor resource setting lacks the competence and ability to build health facilities to cover the entire country, especially in our rural areas. As a result, patients often go through long distances to access competent health services such as emergency obstetrics care, like caesarean section. This, coupled with poor transport facilities, and poverty contributes immensely to delay in hospital arrival, and intervention. It’s not therefore surprising that the rate of birth asphyxia is bound to be high in our environment.
The high rate of birth asphyxia we got from our study (17.4%) is not acceptable by western standards, where the rate is as low as 2 per 1000 births, largely due to advancement in obstetrics services. [15] However, our rate is comparable to what was reported in some centers in the developing world; 18% in Ethiopia, [17] 16.6 % at Federal Medical Centre, Yenagoa, [22] and 29 % in Port Harcourt, Nigeria. [16]
A very formidable danger of birth asphyxia is its potential to cause high rates of perinatal mortality, and disability among the survivors. Nigeria has one of the highest perinatal mortality rates secondary to birth asphyxia globally; 31.1% at Irrua, Edo State, [23] 32.1% in Port Harcourt, [24] 42.1% in Osogbo, [25] and 25.5% in Gusua. [20]. These were however much higher than the 5.4% we obtained in NDUTH, probably due to that fact that most of the studies above focused on severe birth asphyxia. Secondly, our study was limited to only emergency caesarean section.
In my opinion, the neonatal mortality rates in Nigeria are grossly under reported. This is because many neonatal deaths occur in our rural areas, where facilities for proper record keeping are not available. There are very few well equipped neonatal centers in Nigeria, with the right complement of manpower. Most states in Nigeria have only one or two neonatal units, which are located in the tertiary institutions in the states capitals.
Unbooked status (lack of antenatal care), a significant obstetric factor for birth asphyxia, as we observed in our study seems to be a global phenomenon; similar results were reported at Irrua Specialist Hospital in Nigeria, [23] Benishangul-Gumuz Region Hospital in Ethiopia, [26] and Karachi in Pakistan. [27] This is because unbooked patients who developed obstetrics complications during labour are less likely to be diagnosed on time, and medical intervention is likely to be delayed, from late arrival in hospital.
In Nigeria, our pregnant women have a high affinity to deliver outside the hospital setting, especially with traditional birth attendants. A previous study has reported that in rural parts of Africa, 60% to 90% of pregnant women deliver with TBA. [28] This practice is mostly driven by illiteracy, poverty, and lack of skilled health services within the locality. TBAs are largely unskilled, and they are not in a position to diagnose and manage obstetrics complications. As a result, the maternal and fetal mortality and morbidity is very high among women who deliver with a TBA. [29, 30] Our study has also proven that they refer patients to hospital late, and this has resulted in significant increase in the rate of birth asphyxia.
When pregnant women in labour have been diagnosed with an obstetrics complication, and the decision to deliver by emergency caesarean section has been taken, surgery should be prompt and timely. Undue delay worsens the complications, and increases the rate of mortality and morbidity. [31, 32] Within the hospital setting in Nigeria, logistic problem are quite frequently, and this often rubs the surgeon’s desire for timely intervention; by slowing down the process. Previous studies have identified these as hospital, laboratory and patient related logistic factors. [33, 34]
The impact of hospital logistic problem as a delaying factor for emergency caesarean section has been reported in some centers in Nigeria. Studies in Ibadan, and Port Harcourt reported hospital logistic problems as the cause of delay in 43.6 %, and 18.8% respectively. [35, 36] Our study has proven beyond reasonable doubt that undue delay from some of these factors significantly increases the rate of birth asphyxia.
Among the logistic factor in our environment, interrupted power supply seems to predominate; it frequently disrupts operative activities in our hospital. This is very worrisome in emergency caesarean section, because it puts both fetal and maternal lives at risk. Electricity supply is paramount to the functioning of surgical equipment, water supply, instrument sterilization among others. There are instances where absence of electricity delays onset of surgery for several hours, especially when the hospital back-up power supply is faulty.
A study at Ogbomoso in Nigeria reported power outrage as the main reason why 28% of the emergency caesarean sections did not start early. [33] Our study has further buttressed this finding by proving that delay from interrupted power supply causes significant fetal morbidity, by increasing the chances of birth asphyxia by 2 folds, odds ratio = 2.48[0.97, 6.32].
In Nigeria, aversion to caesarean section is very common, and a rate of 20.9% was reported in a previous study. [37] Its a common practice for pregnant women to delay or even refuse surgery at the expense of their lives, and that of their babies. Also, our socio- cultural practices often aggravates the situation; our women often rely on their husbands, and even their pastors to take major decision concerning their health.
A study at Ibadan in Nigeria on women undergoing caesarean section, it was reported that the husband is the sole decision makers on health issues in 58.7% of the patients. [38] Another study in Nigeria revealed that 62.9% of the consents were given by the husband, 31.5% by the relatives, and only 5.6% by the patient. [39] This ultimately results in undue delay in obtaining consent for the emergency caesarean section; sometimes the husbands, or relatives takes several hours to arrive after decision has been taken. A study in Zaria, Nigeria observed that 66.0% of the informed consents for obstetric emergencies were delayed, with a mean time of 4.5 + 3.5 hour.
Undue delay in obtaining informed consent for emergency caesarean section has been proven to increases the risk of fetal and maternal complications, such as fetal distress and birth asphyxia. [40] This fact has been vindicated from our study; delay in giving consent increased the rate of birth asphyxia by 2 folds, odds ratio = 2.47[0.77, 7.97].
As it has been stated earlier, birth asphyxia has been widely studied globally, and there are many publications on this subject matter, however, it’s associated, and risk factors were based mainly on obstetrics factors. In West African, where hospital logistic problems are ubiquitous, there is dearth of publications on the impact of these factors on perinatal asphyxia.
We have been able to establish a significant link in NDUTH, we hereby advocate that similar studies should be carried out in other centres in West Africa, to validate our findings. This would on the long run serve as a fulcrum to expand the scope of preventing this highly fatal disease condition.
During emergency caesarean section, obstetrics factors are undoubtedly central to the pathogenesis of birth asphyxia. However, this study has brought to limelight the significant role played by hospital logistic factors that delays onset of surgery. Eradicating these factors in our hospital settings could save the lives of our babies.
Conflict of Interest: The authors have declared there was no conflict of interest.
Acknowledgement: The authors wishes to acknowledge the Head of Department of Obstetrics and Gynaecology NDUTH.
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