Severe neonatal birth injury: Observational study of associations with operative, cesarean, and spontaneous vaginal delivery

Abstract

Aim: To determine the association of successful and unsuccessful operative vaginal delivery attempts with risk of severe neonatal birth injury.

Methods: We conducted a population-based observational study of 1 080 503 births between 2006 and 2019 in Quebec, Canada. The main exposure was operative vaginal delivery with forceps or vacuum, elective or emergency cesarean with or without an operative vaginal attempt, and spontaneous delivery. The outcome was severe birth injury, including intracranial hemorrhage, brain and spinal damage, Erb's paralysis and other brachial plexus injuries, epicranial subaponeurotic hemorrhage, skull and long bone fractures, and liver, spleen, and other neonatal body injuries. We determined the association of delivery mode with risk of severe birth injury using adjusted risk ratios (RR) and 95% confidence intervals (CI).

Results: A total of 8194 infants (0.8%) had severe birth injuries. Compared with spontaneous delivery, vacuum (RR 2.98, 95% CI 2.80-3.16) and forceps (RR 3.35, 95% CI 3.07-3.66) were both associated with risk of severe injury. Forceps was associated with intracranial hemorrhage (RR 16.4, 95% CI 10.1-26.6) and brain and spinal damage (RR 13.5, 95% CI 5.72-32.0), while vacuum was associated with epicranial subaponeurotic hemorrhage (RR 27.5, 95% CI 20.8-36.4) and skull fractures (RR 2.04, 95% CI 1.86-2.25). Emergency cesarean after an unsuccessful operative attempt was associated with intracranial and epicranial subaponeurotic hemorrhage, but elective and other emergency cesareans were not associated with severe injury.

Conclusions: Operative vaginal delivery and unsuccessful operative attempts that result in an emergency cesarean are associated with elevated risks of severe birth injury.

Keywords: birth injury; cesarean section; obstetric delivery; obstetric forceps; obstetric vacuum extraction.