Research www. AJOG.

org

OBSTETRICS
Route of delivery and neonatal birth trauma
Charmaine K. Moczygemba, MD; Pangaja Paramsothy, MPH; Susan Meikle, MD, MSPH;
Athena P. Kourtis, MD, PhD, MPH; Wanda D. Barfield, MD, MPH; Elena Kuklina, MD, PhD;
Samuel F. Posner, PhD; Maura K. Whiteman, PhD; Denise J. Jamieson, MD, MPH

OBJECTIVE: We sought to examine rates of birth trauma in 2 groupings
(all International Classification of Diseases, Ninth Revision codes for
birth trauma, and as defined by the Agency for Healthcare Research and
Quality Patient Safety Indicator [PSI]) among infants born by vaginal and
cesarean delivery.
STUDY DESIGN: Data on singleton infants were obtained from the
2004-2005 Healthcare Cost and Utilization Project Nationwide Inpa-
tient Sample.
RESULTS: The rates of Agency for Healthcare Research and Quality PSI
and all birth trauma were 2.45 and 25.85 per 1000 births, respectively.
Compared with vaginal, cesarean delivery was associated with in-
creased odds of PSI birth trauma (odds ratio [OR], 1.71), primarily due
to an increased risk for “other specified birth trauma” (OR, 2.61). Con-
versely, cesarean delivery was associated with decreased odds of all
birth trauma (OR, 0.55), due to decreased odds of clavicle fractures
(OR, 0.07), brachial plexus (OR, 0.10), and scalp injuries (OR, 0.55).
CONCLUSION: Infants delivered by cesarean are at risk for different
types of birth trauma from infants delivered vaginally.
Key words: neonatal birth trauma, patient safety, route of delivery

Cite this article as: Moczygemba CK, Paramsothy P, Meikle S, et al. Route of delivery and neonatal birth trauma. Am J Obstet Gynecol 2010;202:361.e1-6.

C esarean delivery is the most com-

mon major surgical procedure in
the United States and rates have in-
tention on the importance of patient
safety in all fields of medicine.2 In re-
sponse, the Agency for Healthcare Re-
trauma. We also examine another clini-
cal grouping of birth trauma codes (all
birth trauma) made up of all codes found
creased from 22.8% in 1989 to 30.3% in search and Quality (AHRQ) has devel- in the birth trauma section of the ICD-9
2005.1 There are known risks to mother oped a group of Patient Safety Indicators coding manual, to capture the total
and fetus during both vaginal and cesar- (PSIs). A PSI is a set of International amount of neonatal birth trauma in the
ean deliveries. Although a number of Classification of Diseases, Ninth Revision United States. In addition, we examine
studies examine maternal safety associ- (ICD-9) codes that represent outcomes individual types of birth trauma. Fur-
ated with cesarean delivery, there are few considered avoidable through practice thermore, potential associations of birth
studies that address neonatal safety. In modification. These indicators were trauma with clinical and demographic
the era of rapidly increasing cesarean de- chosen by a group of experts through lit- factors such as route of delivery, birth-
livery rates, neonatal safety data are ur- erature review, consensus development, weight, and presence of fetal distress are
gently needed to monitor the quality of and public comment, but have not been examined. We hypothesized that the
care and better counsel obstetric pa- validated.3 A PSI was developed for birth rates of individual types of neonatal birth
tients. In 2000, the Institute of Medicine trauma and included 7 types of neonatal trauma, rather than any 1 grouping,
published “To Err Is Human: Building a birth trauma. Our study uses this AHRQ would vary by route of delivery.
Safer Health System,” which focused at- PSI for examining national rates of birth
M ATERIALS AND M ETHODS
From the Department of Gynecology and Obstetrics, Emory University (Drs Moczygemba Hospital discharge data from the Na-
and Jamieson), Atlanta, GA; the Division of Reproductive Health, National Center for tionwide Inpatient Sample (NIS), 2004-
Chronic Disease Prevention and Health Promotion, Centers for Disease Control and 2005, were obtained from the Health-
Prevention (Drs Kourtis, Barfield, Posner, Whiteman, and Jamieson), Atlanta, GA; and care Cost and Utilization Project. The
Northrop Grumman Civilian Group (Dr Kuklina), Atlanta, GA; Contraceptive Research And Healthcare Cost and Utilization Project
Development Program, Arlington, VA (Ms Paramsothy); and Contraceptive and is a group of health care databases and
Reproductive Health Branch/National Institutes of Health (the Eunice Kennedy Shriver related software tools that were devel-
National Institute of Child Health and Human Development), Bethesda, MD (Dr Meikle).
oped through a partnership with private
Presented at the District IV Meeting of the American College of Obstetricians and Gynecologists, and public state level data collection or-
Orlando, FL, Sept. 5-7, 2008.
ganizations and sponsored by the
Received June 9, 2009; revised Sept. 12, 2009; accepted Nov. 14, 2009.
AHRQ. The NIS is the largest all-payer
Reprints: Charmaine K. Moczygemba, MD, Department of Gynecology and Obstetrics, Emory
School of Medicine, 69 Jesse Hill Jr Dr., Fourth Floor, Atlanta, GA 30303.
inpatient care database publicly available
cmoczygemba@gmail.com. in the United States.
0002-9378/$36.00 • © 2010 Mosby, Inc. All rights reserved. • doi: 10.1016/j.ajog.2009.11.041 The sampling universe for NIS in-
cludes US community hospitals that are

APRIL 2010 American Journal of Obstetrics & Gynecology 361.e1

Research Obstetrics
open during any part of the calendar year
and are designated as community hospi-
tals by the American Hospital Associa-
tion Annual Survey of Hospitals. Com-
munity hospitals are defined as all
nonfederal general and specialty hospi-
tals, with average length of stays ⬍30
days, and whose facilities are open to the
public. This definition includes specialty
hospitals such as orthopedic, pediatric,
obstetrics-gynecology, and ear-nose-
throat institutions, as well as public hos-
pitals and academic medical centers. A
hospital is considered to be a teaching
hospital if it has an American Medical
Association-approved residency pro-
gram, is a member of the Council of
Teaching Hospitals, or has a ratio of full-
time equivalent interns and residents to
beds of ⱖ .25. Veterans hospitals and
other federal hospitals, rehabilitation
hospitals, psychiatric hospitals, and alco-
hol/chemical dependency treatment fa-
cilities are not included in the sample.
Data are gathered from all community
hospitals within each participating state.
Hospitals may vary from year to year
based on state participation, but this
change is accounted for by the below
sampling strategy. In 2004 and 2005, 37
states contributed data.4
For each year, the NIS is designed to
approximate a 20% stratified sample of
community hospitals in the United
States and contains discharge data for
approximately 8 million hospital stays
from ⬎1000 hospitals. The sampling
frame for NIS uses 5 strata: type of own-
ership, number of hospital beds, teach-
ing status, urban or rural location, and
region of the country. For each sampled
hospital, 100% of the discharges are re-
tained. These sampling probabilities are
used to create a “weight” for each hospi-
tal so when appropriate statistical tools
are used, estimates reflect a national
sample of community hospitals. That is
why we present weighted data, not un-
weighted data. For each change to the
sampling frame, AHQR compares indi-
vidual years of the NIS with the corre-
sponding National Hospital Discharge
Survey and with the Medicare Provider
Analysis and Review file to check for
consistency and validate the dataset.
361.e2 American Journal of Obstetrics & Gynecology APRIL 2010
Hospital discharge diagnoses were
classified using the ICD-9, Clinical Mod-
ification (ICD-9-CM) codes. Singleton
live born infants were identified using
ICD-9-CM diagnosis codes and classi-
fied as either vaginal birth (V30.00,
V39.00) or cesarean birth (V30.01,
V39.01). Birthweight was defined as low
(764.01-764.08, 764.11-764.18, 765.01-
765.08, 765.11-765.18), high (766.0,
766.1), or average. Since there are no
specific codes for average birthweight,
newborns without codes specifying low
birthweight or high birthweight were
considered average. Presence of fetal dis-
tress was defined by ICD-9-CM codes
763.81, 763.82, 763.83, 768.2, 768.3, and
768.4.
Neonatal birth traumas were defined
as subdural and cerebral hemorrhage
(767.0), epicranial subaponeurotic hem-
orrhage (767.11), other injuries to scalp
(767.19), fracture of clavicle (767.2),
other injures to skeleton (767.3), injury
to spine and spinal cord (767.4), facial
nerve injury (767.5), injury to brachial
plexus (767.6), other cranial and periph-
eral nerve injuries (767.7), other speci-
fied birth trauma (767.8), and birth
trauma unspecified (767.9). Other spec-
ified birth trauma (767.8) includes he-
matoma or injury to sternocleidomas-
toid; hematoma or rupture of spleen,
liver; teste; vulva; viscera; kidney or
stomach; injury or damage to eye or
traumatic glaucoma; fetal laceration by
scalpel. Other injuries to scalp (767.19)
included caput succedaneum, cephalo-
hematoma, and chignon (from vacuum
extraction). If an infant had a diagnosis
of subdural and cerebral hemorrhage
and was defined as preterm (765.01-
765.09, 765.11-765.19, 765.21-765.28),
then the diagnosis was not considered a
birth trauma. If an infant had a diagnosis
of other injuries to skeleton or injury to
spine and spinal cord and had a diagno-
sis of osteogenesis imperfecta (756.51),
then the diagnosis was not considered a
birth trauma.
Birth traumas were examined in 2
groups as well as individually. The
AHRQ PSI birth trauma includes the 7
types of birth trauma: (1) subdural and
cerebral hemorrhage, (2) epicranial sub-
aponeurotic hemorrhage, (3) other inju-
www.AJOG.org
ries to skeleton, (4) injury to spine and
spinal cord, (5) other cranial and periph-
eral nerve injuries, (6) other specified
birth trauma, and (7) birth trauma un-
specified. In addition, we created and ex-
amined a new all-inclusive group of neo-
natal birth trauma, called “all birth
trauma,” which includes the 7 PSI birth
traumas as well as 4 additional birth
traumas: (1) other injuries to scalp, (2)
fracture to clavicle, (3) facial nerve in-
jury, and (4) injury to brachial plexus.
Primary payer was defined as public
(Medicare/Medicaid), private (private
insurance), or other (self-pay, no insur-
ance). For each hospital, the number of
liveborn singleton deliveries per year
were categorized as ⱕ400, 401-1300, or
⬎1300. Hospital teaching type and loca-
tion were combined and defined as rural,
urban nonteaching, and urban teaching.
To account for the complex sampling
design, we used software (SAS-callable
SUDAAN, v. 9.1; Research Triangle In-
stitute, Research Triangle Park, NC) to
analyze the data. Rates, along with the
95% confidence interval (CI), were cal-
culated per 1000 singleton live hospital
births. Logistic regression was used to es-
timate both unadjusted and adjusted
odds ratio (aOR) as well as correspond-
ing 95% CI. Interaction between route of
delivery and neonatal birthweight, and
route of delivery and presence of fetal
distress, was evaluated and considered to
be present if P ⬍ .01. Programming and
data results were confirmed by 2 inde-
pendent researchers. Since the NIS data
do not contain personal identifiers and
are publicly available administrative
data, the Centers for Disease Control and
Prevention determined this research to
be exempt research not requiring review
by an institutional review board.
R ESULTS
Our study population included a
weighted sample of 8,176,523 live single-
ton newborns born in a hospital in 2004
and 2005. The proportion of singleton
neonates born by cesarean delivery was
29.52%. The proportions of low and
high birthweight infants were 4.44% and
5.77%, respectively. The proportion of
www.AJOG.org Obstetrics Research

TABLE 1
Neonatal characteristics and birth trauma rates
AHRQ PSI birth Unadjusted OR Unadjusted OR
trauma ratec for PSI birth All birth trauma for all birth
Variable na nb Percent (95% CI) trauma (95% CI) ratec (95% CI) trauma (95% CI)
d
Sex of infant
.......................................................................................................................................................................................................................................................................................................................................................................
Male 861,461 4,176,147 51.19 2.63 (2.35–2.91) 1.16 (1.09–1.24) 28.74 (27.25–30.22) 1.27 (1.23–1.31)
.......................................................................................................................................................................................................................................................................................................................................................................
Female 821,455 3,982,713 48.80 2.27 (2.00–2.54) Referent 22.80 (21.41–24.19) Referent
................................................................................................................................................................................................................................................................................................................................................................................
Primary payer
.......................................................................................................................................................................................................................................................................................................................................................................
Public 699,742 3,385,847 41.41 2.23 (2.00–2.46) 0.90 (0.75–1.07) 25.38 (23.55–27.21) 0.99 (0.90–1.09)
.......................................................................................................................................................................................................................................................................................................................................................................
Private 865,135 4,201,515 51.39 2.63 (2.25–3.02) 1.06 (0.87–1.30) 26.26 (24.68–27.85) 1.03 (0.93–1.13)
.......................................................................................................................................................................................................................................................................................................................................................................
Other 121,657 589,161 7.20 2.48 (2.07–2.89) Referent 25.58 (23.28–27.88) Referent
................................................................................................................................................................................................................................................................................................................................................................................
Delivery route
.......................................................................................................................................................................................................................................................................................................................................................................
Cesarean 498,451 2,413,979 29.52 3.46 (3.13–3.79) 1.71 (1.56–1.87) 17.07 (16.02–18.11) 0.57 (0.55–0.59)
.......................................................................................................................................................................................................................................................................................................................................................................
Vaginal 1,188,083 5,762,544 70.48 2.03 (1.77–2.29) Referent 29.53 (27.92–31.13) Referent
................................................................................................................................................................................................................................................................................................................................................................................
Birthweight
.......................................................................................................................................................................................................................................................................................................................................................................
Low 75,053 362,921 4.44 3.26 (2.78–3.75) 1.42 (1.23–1.63) 15.94 (14.55–17.34) 0.63 (0.59–0.68)
.......................................................................................................................................................................................................................................................................................................................................................................
Normal 1,513,724 7,341,681 89.79 2.30 (2.04–2.57) Referent 25.04 (23.67–26.40) Referent
.......................................................................................................................................................................................................................................................................................................................................................................
High 97,757 471,921 5.77 4.17 (3.60–4.74) 1.81 (1.60–2.05) 46.09 (43.33–48.84) 1.88 (1.79–1.98)
................................................................................................................................................................................................................................................................................................................................................................................
Fetal distress
.......................................................................................................................................................................................................................................................................................................................................................................
Present 10,080 48,855 0.60 6.75 (5.02–8.48) 2.79 (2.13–3.65) 64.15 (52.61–75.69) 2.61 (2.17–3.14)
.......................................................................................................................................................................................................................................................................................................................................................................
Absent 1,676,454 8,127,668 99.40 2.43 (2.16–2.69) Referent 25.62 (24.26–26.98) Referent
................................................................................................................................................................................................................................................................................................................................................................................
Admission on
weekendd
.......................................................................................................................................................................................................................................................................................................................................................................
Yes 342,303 1,659,934 20.30 2.64 (2.32–2.95) 1.10 (1.01–1.18) 28.57 (26.96–30.18) 1.14 (1.11–1.17)
.......................................................................................................................................................................................................................................................................................................................................................................
No 1,344,230 6,516,584 79.70 2.41 (2.14–2.67) Referent 25.16 (23.80–26.51) Referent
................................................................................................................................................................................................................................................................................................................................................................................
No. of singleton
deliveries/y at
hospitald
.......................................................................................................................................................................................................................................................................................................................................................................
ⱕ400 83,916 427,354 5.23 1.98 (1.50–2.47) 0.79 (0.60–1.04) 19.93 (17.78–22.08) 0.76 (0.67–0.86)
.......................................................................................................................................................................................................................................................................................................................................................................
401–1300 358,435 1,736,210 21.23 2.35 (1.93–2.76) 0.93 (0.75–1.16) 26.29 (23.87–28.71) 1.01 (0.89–1.13)
.......................................................................................................................................................................................................................................................................................................................................................................
ⱖ1301 1,244,183 6,012,958 73.54 2.52 (2.18–2.85) Referent 26.14 (24.40–27.89) Referent
................................................................................................................................................................................................................................................................................................................................................................................
Hospital location and
teaching typed
.......................................................................................................................................................................................................................................................................................................................................................................
Rural 185,118 937,600 11.47 2.32 (1.62–3.02) 0.81 (0.57–1.14) 22.28 (19.95–24.61) 0.83 (0.72–0.96)
.......................................................................................................................................................................................................................................................................................................................................................................
Urban nonteaching 771,587 3,706,117 45.33 2.10 (1.79–2.42) 0.73 (0.59–0.92) 25.96 (23.94–27.98) 0.97 (0.86–1.10)
.......................................................................................................................................................................................................................................................................................................................................................................
Urban teaching 729,829 3,532,807 43.20 2.86 (2.38–3.34) Referent 26.68 (24.37–28.99) Referent
................................................................................................................................................................................................................................................................................................................................................................................
AHRQ, Agency for Healthcare Research and Quality; CI, confidence interval; OR, odds ratio; PSI, Patient Safety Indicator.
a
Unweighted number of live singleton births; b Weighted number of live singleton births; c Rate is per thousand singleton live births; d Sample size does not equal to 8,176,523, due to missing date
and/or rounding error.
Moczygemba. Route of delivery and neonatal birth trauma. Am J Obstet Gynecol 2010.

infants with fetal distress prior to deliv- male, delivered by cesarean delivery, low trauma. Similarly, infants who were male,
ery was 0.60% (Table 1). birthweight, high birthweight, born with high birthweight, born with documented
The rate of AHRQ PSI birth trauma was documented fetal distress, or admitted on fetal distress, or admitted on a weekend
2.45 per 1000 births (95% CI, 2.19 –2.72) a weekend were all groups at increased were all groups at increased odds for all
and the rate of all birth trauma was 25.85 odds for AHRQ PSI birth trauma. Infants birth trauma. Infants born by cesarean de-
per 1000 births (95% CI, 24.47–27.23). In born in urban nonteaching hospitals had livery, low birthweight, in a hospital with
unadjusted analyses, infants who were decreased odds of AHRQ PSI birth ⱕ400 deliveries per year, or in a rural hos-

APRIL 2010 American Journal of Obstetrics & Gynecology 361.e3

Research Obstetrics
FIGURE
Distribution of neonatal birth trauma
Distribution of all neonatal birth trauma and birth trauma considered to be a Patient Safety Indicator
(PSI) by Agency for Healthcare Research and Quality (AHRQ)
EGA, estimated gestational age.
Moczygemba. Route of delivery and neonatal birth trauma. Am J Obstet Gynecol 2010.
pital were at decreased odds for all birth
trauma (Table 1).
The birth trauma category “other in-
juries to scalp,” which is not included in
the AHRQ PSI, accounted for a majority
of all birth trauma (78.24%) in the
United States. AHRQ PSI birth trauma
accounted for 9.62% of total birth
trauma. The largest type within the
AHRQ PSI birth trauma group was
“other specified birth trauma” (6.34%)
(Figure).
Overall, when comparing cesarean de-
livery with vaginal delivery, the odds of
AHRQ PSI birth trauma were higher for
cesarean delivery (aOR 1.65; 95% CI,
1.51–1.81) whereas the odds of all birth
trauma were lower for cesarean delivery
(aOR 0.55; 95% CI, 0.53– 0.58). The
rates of other injuries to scalp, fracture to
clavicle, and injury to brachial plexus
were all lower among cesarean deliveries.
The rate of “other specified birth
trauma” was lower in vaginal delivery.
The rates of epicranial subaponeurotic
hemorrhage, subdural and cerebral
hemorrhage, other injuries to skeleton,
birth trauma unspecified, and facial
361.e4 American Journal of Obstetrics & Gynecology APRIL 2010
nerve injury were similar among cesar-
ean and vaginal deliveries. The weighted
samples for “injury to spine and spinal
cord” and “other cranial or peripheral
nerve” were too small to calculate rates
and compare (Table 2).
The relationship between route of de-
livery and AHRQ PSI birth trauma var-
ied according to the presence or absence
of fetal distress at delivery and according
to birthweight (P interaction ⬍ .01).
When fetal distress was absent, the odds
of AHRQ PSI birth traumas were higher
among cesarean deliveries compared
with vaginal deliveries (aOR, 1.66; 95%
CI, 1.52–1.82), whereas in the presence
of fetal distress the odds of PSI birth
trauma were not significantly different
when comparing cesarean and vaginal
deliveries (aOR, 1.09; 95% CI, 0.66-
1.80). Among low and average fetal
birthweight groups, cesarean delivery
was associated with an increased odds of
AHRQ PSI birth trauma (aOR, 2.22;
95% CI, 1.71–2.89; and aOR, 1.76; 95%
CI, 1.60 –1.93), respectively), whereas
the odds of AHRQ PSI birth trauma
among large birthweight infants were
www.AJOG.org
not significantly different between cesar-
ean and vaginal deliveries (aOR, 0.83;
95% CI, 0.67–1.04) (Table 3). When we
examined all birth trauma outcome
group, cesarean delivery was consistently
associated with a reduced odds of birth
trauma compared to vaginal delivery
across all fetal distress and birthweight
subgroups (Table 3).
C OMMENT
Our study provides nationwide esti-
mates of birth trauma, with approxi-
mately 2.6% of births complicated by
some type of birth trauma. We also
provide a nationwide estimate of the
PSI for neonatal birth trauma as de-
fined by AHRQ, which is the only
published grouping of birth trauma
considered modifiable by changing
physician practices.
The association between cesarean de-
livery and neonatal birth trauma changes
direction when examining the 2 birth
trauma groupings because the associa-
tion varies by individual type of birth
trauma. Compared with vaginal deliv-
ery, cesarean delivery was associated
with increased odds of PSI birth trauma,
primarily due to increased odds for
“other specified birth trauma.” Since the
driving ICD-9 code includes 11 distinct
types of birth trauma that do not have
their own separate codes or qualifiers, it
is difficult to determine exactly what type
of birth trauma is responsible for the
positive association between cesarean
delivery and neonatal birth trauma.
Conversely, cesarean delivery was associ-
ated with decreased odds of all birth
trauma, primarily due to decreased odds
of clavicle fractures and injuries to the
brachial plexus and scalp. These 3 codes,
which are not included within the
AHRQ PSI, have a strong association
with vaginal delivery and result in a
change in direction of the association of
cesarean delivery with all neonatal birth
trauma, despite the inclusion of the
AHRQ PSI ICD-9 codes within this
grouping.
The association between route of de-
livery and birth trauma also varies by fe-
tal characteristics. In the absence of fetal
distress and among low or average birth-
www.AJOG.org Obstetrics Research

TABLE 2
Specific birth trauma rates
Ratea for cesarean Ratea for vaginal aORb (95% CI) cesarean
Type of birth trauma (ICD-9 code) delivery (95% CI) delivery (95% CI) vs vaginal delivery
Subdural and cerebral hemorrhage (767.0)c,d 0.23 (0.18–0.27) 0.19 (0.16–0.22) 1.22 (0.97–1.54)
................................................................................................................................................................................................................................................................................................................................................................................
Epicranial subaponeurotic hemorrhage (massive) 0.15 (0.11–0.18) 0.11 (0.09–0.13) 1.26 (0.93–1.72)
(767.11)c
................................................................................................................................................................................................................................................................................................................................................................................
c,e
Other injuries to skeleton (767.3) 0.33 (0.23–0.44) 0.34 (0.23–0.44) 0.95 (0.77–1.17)
................................................................................................................................................................................................................................................................................................................................................................................
c f f
Injury to spine or spinal cord (767.4) N/A
................................................................................................................................................................................................................................................................................................................................................................................
c f
Other cranial or peripheral nerve injury (767.7) 0.04 (0.03–0.06) N/A
................................................................................................................................................................................................................................................................................................................................................................................
c g
Other specified birth trauma (767.8) 2.61 (2.38–2.85) 1.23 (1.05–1.41) 2.07 (1.84–2.32)
................................................................................................................................................................................................................................................................................................................................................................................
c
Birth trauma unspecified (767.9) 0.17 (0.08–0.27) 0.15 (0.07–0.23) 1.16 (0.94–1.43)
................................................................................................................................................................................................................................................................................................................................................................................
h g
AHRQ PSI birth trauma 3.46 (3.13–3.79) 2.03 (1.77–2.29) 1.65 (1.51–1.81)
................................................................................................................................................................................................................................................................................................................................................................................
g
Other injuries to scalp (767.19) 13.15 (12.24–14.07) 23.17 (21.64–24.70) 0.55 (0.53–0.58)
................................................................................................................................................................................................................................................................................................................................................................................
Fracture to clavicle (767.2) 0.25 (0.20–0.30) 3.29 (2.98–3.60) 0.07 (0.06–0.09)
................................................................................................................................................................................................................................................................................................................................................................................
Facial nerve injury (767.5) 0.24 (0.20–0.29) 0.22 (0.19–0.25) 1.07 (0.85–1.34)
................................................................................................................................................................................................................................................................................................................................................................................
Injury to brachial plexus (767.6) 0.17 (0.13–0.21) 1.49 (1.39–1.58) 0.10 (0.08–0.13)
................................................................................................................................................................................................................................................................................................................................................................................
h g
Birth trauma–all 17.07 (16.02–18.11) 29.53 (27.92–31.13) 0.55 (0.53–0.58)
................................................................................................................................................................................................................................................................................................................................................................................
AHRQ, Agency for Healthcare Research and Quality; aOR, adjusted odds ratio; CI, confidence interval; ICD-9, International Classification of Diseases, Ninth Revision; N/A, because of small numbers
we were unable to construct multivariate models; PSI, Patient Safety Indicator.
a
Adjusted for birthweight, sex, and admission on weekend; b Rates are per thousand singleton births; c AHRQ PSI birth trauma; d Excluding infants weighing ⬍2500 g or estimated gestational age ⬍37
wk, when using AHRQ guidelines for PSIs; e Excluding infants with diagnosis osteogenesis imperfecta, when using AHRQ guidelines for PSIs; f Unstable estimate relative SE ⬎ .3; g Model also adjusted
for fetal distress; h Values were calculated from number of neonates with at least 1 type of AHRQ PSI birth trauma or all birth trauma, therefore a neonate with ⬎1 injury would only be counted once.
Moczygemba. Route of delivery and neonatal birth trauma. Am J Obstet Gynecol 2010.

weight babies, cesarean delivery is asso- physical disability. It is difficult to characteristics. These are variables that
ciated with increased odds of AHRQ PSI draw conclusions about safety from a are not modifiable. Grobman et al5 ex-
birth trauma compared to vaginal deliv- rate that represents a collective group amined the AHRQ PSI for obstetric
ery. Otherwise, in neonates with fetal of diagnoses with varying clinical con- trauma and found those diagnoses to
distress and large birthweight, the odds sequence. Finally, our findings demon- significantly vary by patient and hospi-
of AHRQ PSI are not significantly differ- strate that the rate of AHRQ PSI birth tal characteristics as well, and they con-
ent between cesarean and vaginal deliv- trauma changes when considering dif- cluded that the obstetric PSI was not a
ery. Cesarean delivery is associated with ferent patient populations and hospital good indicator of patient safety.
a reduced odds of all birth trauma com-
pared to vaginal delivery across all fetal
TABLE 3
distress and birthweight subgroups.
Although we are unable to directly
Odds of birth trauma by fetal distress and birthweight
assess the validity of the AHRQ PSI as a AHRQ PSI birth trauma, aOR All birth trauma, aOR
tool to measure safety, our findings do Variable (95% CI) (95% CI)
highlight some limitations and some Fetal distress
.....................................................................................................................................................................................................................................
areas for future research. As men- Present 1.09 (0.66–1.80) a
0.40 (0.31–0.52) a
.....................................................................................................................................................................................................................................
tioned above, the prevailing ICD-9 Absent 1.66 (1.52–1.82) a
0.56 (0.53–0.58) a

code “other specified birth trauma,” ..............................................................................................................................................................................................................................................

Birthweight
which makes up 58% of the AHRQ PSI, .....................................................................................................................................................................................................................................
b b
represents 11 types of birth trauma Low (⬍2500 g) 2.22 (1.71–2.89) 0.51 (0.45–0.58)
.....................................................................................................................................................................................................................................
that are impossible to separate when Normal c
1.76 (1.60–1.93) b
0.58 (0.56–0.61) b
.....................................................................................................................................................................................................................................
using administrative data. Addition- High d
0.83 (0.67–1.04) b
0.39 (0.36–0.58) b

ally, the diagnoses included within the ..............................................................................................................................................................................................................................................

AHRQ, Agency for Healthcare Research and Quality; aOR, adjusted odds ratio; CI, confidence interval; PSI, Patient Safety
AHRQ PSI, as well as within “other Indicator.
specified birth trauma,” represent a a
Adjusted by birthweight, sex, and admission on weekend; b Adjusted for fetal distress, sex, and admission on weekend; c All
spectrum of severity and long-term newborns without International Classification of Diseases, Ninth Revision (ICD-9) codes indicating weight ⬍2500 g (low
birthweight) or high birthweight; d ICD-9 codes 766.0 (exceptionally large baby) and 766.1 (other “heavy for dates” infants).
morbidity that ranges from inconse- Moczygemba. Route of delivery and neonatal birth trauma. Am J Obstet Gynecol 2010.
quential to sustained neurologic or

APRIL 2010 American Journal of Obstetrics & Gynecology 361.e5

Research Obstetrics
Our study, which utilizes administra-
tive hospital discharge data, has several
limitations. Our data are subject to vary-
ing coding practices among hospitals, as
well as poorly coded conditions of the
neonate, such as neonatal distress during
labor. Due to its cross-sectional design,
causality cannot be inferred. We utilized
neonatal hospital discharge records and
were unable to link these with maternal
discharge data. Therefore, we were un-
able to examine potentially influential
maternal variables such as maternal
weight, presence of diabetes, hyperten-
sion, age, prior cesarean delivery, and
type of vaginal delivery, such as vacuum
or forceps, or the occurrence of a failed
operative delivery. Perhaps most impor-
tantly, we were unable to differentiate
between cesarean deliveries without la-
bor and those following a failed trial of
labor. Because we used ICD-9-CM dis-
charge codes, we were unable to deter-
mine the specific birth traumas repre-
sented by the codes for “other injuries
to scalp” and “other specified birth
trauma.” An important strength of our
study is our large sample size, which al-
lowed us to analyze rare outcomes, such
as individual types of neonatal birth
trauma, and to adjust for and stratify by
clinically important factors such as fetal
distress and birthweight.
Earlier studies examining neonatal
birth trauma are limited by small sample
sizes and generally focus on a small selec-
tion of birth traumas, rather than all
known types.6,7 Most of these studies do
not examine association with route of
delivery.6,8-10 Studies that have exam-
ined the association with route of deliv-
ery have generally found cesarean to be
associated with decreased odds of neo-
natal birth trauma11,12 but did not exam-
ine the effect of birthweight or presence
361.e6 American Journal of Obstetrics & Gynecology APRIL 2010
of fetal distress on this relationship. All
of these studies did find rates of the indi-
vidual types of birth trauma and the as-
sociations with route of delivery that are
similar to our rates presented here. One
exception was the positive association of
cesarean delivery with intracranial hem-
orrhage compared to spontaneous vagi-
nal delivery in a study from California.7
However, the comparison of results is
difficult since in our study all vaginal de-
liveries (spontaneous, vacuum, forceps,
or both vacuum and forceps) were con-
sidered as a reference group. One study
that examined fetal scalp laceration dur-
ing cesarean delivery did find an associ-
ation with presence of fetal distress, but
the study is limited to only this 1 type of
trauma and only in the setting of cesar-
ean delivery.9
To date, much of the research on the
safety of cesarean delivery has focused on
maternal outcomes; our study adds im-
portant information regarding neonatal
outcomes associated with route of deliv-
ery. An underlying assumption in the
practice of obstetrics has been that cesar-
ean delivery is generally safer for the
baby. Therefore, when debating the risks
and benefits of cesarean delivery, atten-
tion has been primarily focused on
weighing maternal risks with neonatal
benefits. Our study demonstrates that
the association between route of delivery
and neonatal birth trauma is not a con-
stant in favor of cesarean delivery and ac-
tually varies by type of trauma. f Development Maternal-Fetal Medicine Units
ACKNOWLEDGMENTS
We thank Aniket Kulkarni and Pooja Bansil for
their considerable assistance with data man-
agement and analysis.
REFERENCES
1. Martin JA, Hamilton BE, Sutton PD, et al.
Births: final data for 2005. National vital statis-
www.AJOG.org
tics reports; vol 56, no. 6. Hyattsville, MD:
National Center for Health Statistics; 2007.
2. Kohn LT, Corrigan JM, Donaldson MS; Insti-
tute of Medicine. To err is human: building a
safer health system. Washington, DC: National
Academy Press; 2000.
3. Agency for Healthcare Research and Quality.
Guide to patient safety indicators. Version 2.1,
revision 3 (January 17, 2005). Available at:
http://www.qualityindicators.ahrq.gov/psi_
download.htm. Accessed May 1, 2007.
4. HCUP Databases. Healthcare cost and utili-
zation project (HCUP). July 2008. Agency for
Healthcare Research and Quality, Rockville,
MD. Available at: http://www.hcup-us.ahrq.
gov/nisoverview.jsp. Accessed May 1, 2007.
5. Grobman WA, Feinglass J, Murthy S. Are the
Agency for Healthcare Research and Quality
obstetric trauma indicators valid measures of
hospital safety? Am J Obstet Gynecol 2006;
195:868-74.
6. Levine MG, Holroyde J, Woods JR Jr, Siddiqi
TA, Scott M, Miodovnik M. Birth trauma: inci-
dence and predisposing factors. Obstet Gy-
necol 1984;63:792-5.
7. Towner D, Castro MA, Eby-Wilkens E, Gilbert
WM. Effect of mode of delivery in nulliparous
women on neonatal intracranial injury. N Engl
J Med 1999;341:1709-14.
8. Tomashek KM, Crouse CJ, Iyasu S, Johnson
CH, Flowers LM. A comparison of morbidity
rates attributable to conditions originating in the
perinatal period among newborns discharged
from United States hospitals, 1989-90 and
1999-2000. Paediatr Perinat Epidemiol 2006;
20:24-34.
9. Dessole S, Cosmi E, Balata A, et al. Acciden-
tal fetal lacerations during cesarean delivery: ex-
perience in an Italian level III university hospital.
Am J Obstet Gynecol 2004;191:1673-7.
10. Alexander JM, Leveno KJ, Hauth J, et al;
National Institute of Child Health and Human
Network. Fetal injuries associated with cesar-
ean delivery. Obstet Gynecol 2006;108:
885-90.
11. Hughes CA, Harley EH, Milmoe G, Bala R,
Martorella A. Birth trauma in the head and neck.
Arch Otolaryngol Head Neck Surg 1999;125:
193-9.
12. Baskett TF, Allen VM, O’Connell CM, Allen
AC. Fetal trauma in term pregnancy. Am J Ob-
stet Gynecol 2007;197:499.e1-7.