INTRODUCTION
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.
AIM AND OBJECTIVES
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.
METHODOLOGY
Study
Site
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.
Study Design
This was a cross-sectional study of 184 women
delivered by emergency caesarean section. It was carried out from January 2022 to
January 2024.
Inclusion Criteria
Included
in this study were both booked and unbooked parturients who developed complications during pregnancy,
and were delivered by emergency caesarean section.
Exclusion Criteria
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.
Sample
Size
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
Collection
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).
Assessment of Delay in Caring out Emergency Caeserean
Section
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
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.
Perinatal Mortality
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
Analysis
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.
Ethical
Approval
Permit to
proceed with this study was granted by the ethical committee of NDUTH, with
registration number NDUTH/REC/0032/2024.
RESULTS
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.
DISCUSSION
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.
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 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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