Birth asphyxia is a major cause of neonatal morbidity and mortality in developing countries. Majority of pregnant women in Nigeria still deliver their babies in places where there are no personnel skilled in essential obstetric care and neonatal resuscitation. Consequently newborns are poorly handled at delivery with resultant poor outcome. We report two cases of iatrogenic burns injuries from hot water formentation in an attempt to resuscitate two neonates at peripheral health care facilities in Ilesa, Nigeria. These babies needlessly sustained burns injuries coupled with hypoxic-ischaemic injuries and poor perinatal outcome. These unfortunate cases of “insults upon injuries” underscore the need to strengthen the primary health care system in Nigeria by training and retraining health workers at these facilities. Proper antenatal care, adequate screening of high risk pregnancy for delivery at adequately equipped centres and making efficient referral system available will go a long way in reducing these needless injuries and morbidities.
Keywords: Birth asphyxia, burns, newborn, resuscitation
|How to cite this article:
Peter KB, Oluwatoyin O, Kehinde KD. Iatrogenic scald injuries in Nigerian babies with perinatal asphyxia: A re-awakening call to strengthen primary health care services. Ann Trop Med Public Health 2015;8:206-9
|How to cite this URL:
Peter KB, Oluwatoyin O, Kehinde KD. Iatrogenic scald injuries in Nigerian babies with perinatal asphyxia: A re-awakening call to strengthen primary health care services. Ann Trop Med Public Health [serial online] 2015 [cited 2017 Nov 14];8:206-9. Available from: https://www.atmph.org/text.asp?2015/8/5/206/159833
Neonatal deaths constitute the bulk of childhood mortality in developing countries, including Nigeria.  This is particularly worse in the rural areas of these countries where most pregnant women often have poor antenatal care and decisions on the mode and place of deliveries are poorly taken. , Consequently, women in these areas deliver their babies at home, on the farm, in traditional birth attendant homes, and in poorly equipped and manned public and private health facilities where personnel skilled in essential obstetric and newborn care are often absent. , Attempts by unskilled birth attendants at delivery places to help mothers and newborns often result in complications and poor perinatal outcomes. ,
We report cases of two neonates referred to our facility (Wesley Guild Hospital, Ilesa) following history of failure to cry and failure to initiate spontaneous respiration at birth. Birth attendants applied hot water formentation to these babies in an attempt to resuscitate them resulting in various degrees of scald injuries. These cases are of interest to underscore the need to strengthen the primary health care facilities. These facilities should be made available and accessible to pregnant women, particularly in rural areas of developing countries and should be well equipped and staffed with personnel skilled in essential health care, including basic obstetric and newborn care.
Baby A, a term female baby was admitted to our unit 4 h after birth in April 2011 with poor cry at birth, inability to suck and difficulty in breathing following vaginal delivery by a 25-year-old Para one woman at a mission house. The health worker at the place of delivery used hot water formentation on the baby in an attempt to resuscitate the baby. The pregnancy was said to be essentially normal, but labor was prolonged.
Father is a banker while mother is a housewife, both with post-secondary school education.
On examination at our center, baby had weight of 2.9 kg and features of term gestation. She was in respiratory distress evidenced by grunting respiration and tachypnea. She had second-degree burn injuries (with blisters) on the trunk and back with an estimated burnt surface area of 30%. Other systemic examinations were essentially normal.
Assessment of severe perinatal asphyxia with iatrogenic major scald injury was made.
Baby A was resuscitated, fluid and electrolyte imbalance corrected, and place on intranasal oxygen, intravenous antibiotics, and incubator care. The burnt area was cleaned with chorhexidine solution and dressed daily with pure natural honey with significant improvement. Baby A was discharged home after 14 days. Follow up at the clinic in infancy revealed delayed development, microcephaly, and failure to thrive.
Baby B, a term male neonate referred from a peripheral government-owned health facility was admitted at our center 21 h after delivery in August 2014, with complaints of failure to cry at birth, multiple episodes of clonic seizures involving both upper limbs of about 10 h and (Lt) sided anterior upper chest wall swelling noticed few minutes after birth. He was delivered via assisted vaginal delivery to a 19-year-old Para one woman. Apgar scores were reported to be 2 1 8 5 10 10 and birth weight was 3.5 kg.
Labor was reportedly augmented by oxytocin infusion as a result of inefficient uterine contraction. At delivery, Baby B was spanked severally, turned upside down, and hot water formentation applied on the anterior chest in an attempt to help the baby breathe.
At admission, Baby B had features of term gestation with caput succedaneum, mildly pale with poor cry and activity and depressed primitive reflexes. There were hyperemic areas with bullous eruptions at the (Lt) anterior chest wall over the (Lt) nipple and areola measuring 6 cm × 8 cm in the widest diameter with erythematous base. Estimated burnt surface area was 8% [Figure 1]. Other examinations findings were normal.
|Figure 1: Scald injury in a newborn with perinatal asphyxia
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An assessment of neonatal seizures secondary to severe perinatal asphyxia with burn injury was made. Baby B was managed as per the unit protocol including incubator care, fluid and calorie maintenance, and intravenous antibiotics and anticonvulsants; area of burn injury was cleansed daily with chorhexidine solution and dressed with pure natural honey. Parents discharged him against medical advice on account of financial constraints at day 12 of admission and did not present for follow up thereafter.
Birth asphyxia is a common occurrence in Nigeria and other developing countries, and is a major reason for admission into the newborn units in Nigeria. , This is not unrelated to poor antenatal care, delivery in the absence of skilled personnel, and a poor referral system. , Pregnant women and their newborns are often left at the mercy of birth attendants with little or no skills in basic obstetric and newborn care, hence the resultant poor perinatal outcome. ,,,,
Our cases typifies the various lapses and deficiencies in the health system vis-à-vis poor case selection by birth attendants at the peripheral health facilities, poor basic obstetrics and neonatal resuscitation skills leading to harmful practices, delay in referral, poor health care financing system and poor health care delivery system.
Case one was referred from a maternity center owned by a religious organization, while case two was referred from government-owned hospital, showing that the deficiencies are present in both public and private sectors of the health system. In a national survey of essential obstetric facilities in Nigeria, Fatusi et al. found that only 18.5% of health care facilities in the country met the criteria of having capacity to offer basic essential obstetric services. This paucity of adequate facilities and manpower has been corroborated by other workers.  This no doubt contributes significantly to poor perinatal outcomes recorded in the country.
The importance of adequate newborn resuscitation cannot be overemphasized. Basic neonatal resuscitation skill is a necessity at every place of delivery. Unfortunately these skills are often not present in most centers that offer primary and secondary cares in Nigeria. 
This is reflected in the handling of the resuscitation of the cases reported. Hot water formentation was applied to our cases leading to major burns injuries. This is not a rare occurrence in our locality, as previously reported by other workers. , Additionally, our cases were slapped, beaten and mishandled in an unwitting attempt to resuscitate them. This calls for urgent need to train and retrain health workers and traditional birth attendants and in indeed everybody involved in newborn care in basic skills of neonatal resuscitation to reduce and stop this injustice to our newborns.
The American Academy of Pediatrics (AAP) in collaboration with the World Health Organization (WHO), U.S. Agency for International Development (USAID), Saving Newborn Lives, and the National Institute of Child Health and Development have proposed a guideline in neonatal resuscitation, practicable even in resource poor settings with the aim of assessing baby at birth, ensuring temperature control, and stimulating breathing and assisted ventilation using AMBU bag as needed in a bid to help baby breathe, within the first minute of life termed the golden minute.  These guidelines are practical and can be carried out at the primary and secondary health facilities with clear instructions on when to refer and steps to be taken during referral. These guidelines are not being followed despite efforts by local pediatric associations to teach and train health workers in these skills of helping baby breathe.  Inadequate number of health workers with these skills results in increasing incidence of perinatal asphyxia, neonatal morbidity and mortality and often harmful practices which often worsen the baby’s condition adding “insults upon injuries.”  We advocate large scale periodic training and retraining of all health workers especially at the primary and secondary health facilities in Nigeria, educating them on appropriate steps in neonatal resuscitation as well as when and how to refer babies that fail to breathe at birth.
Worthy of note is the delay in referring the cases reported. Such secondary delays often result in poor outcome and increased chance of long-term neurologic sequelae, which are confirmed in one of our reported cases. Prolonged severe hypoxic-ischemic injuries to the brain often result in irreversible brain damage manifesting later in life as delayed development and cerebral palsy, among others. 
The inability of the parents of one of our cases to meet the financial requirements of the care of their baby calls to question the health care financing system of the country and its contributions to delay health-seeking behaviors. The health care financing system being predominantly “out of pocket payment system” often leads to financial catastrophe and inability to assess qualitative health care. , There is an urgent need to scale up social insurance system in the country to include the informal sector to facilitate universal coverage particularly as regards essential health needs including basic obstetric and newborn care.
We highlight two cases of babies referred to our facility with perinatal asphyxia worsen with poor and injurious resuscitation approach leading to their sustenance of scald injuries and subsequent poor perinatal outcome. We recognize other factors that contributed to the cases poor outcomes, including absence of personnel skilled in basic obstetric and neonatal care in the facilities where the babies were delivered, a delay in referral systems, a poor health financing system, and a faulty health system. We therefore advocate for strengthening of the health system, training, and retraining of health workers particularly at the peripheral facilities and supervision and evaluation of the primary health care system.
The authors hereby acknowledge the clinicians and nurses who took part in the management of the babies and the parents who gave kind permission for the pictures to be taken and confidential reports of the cases.
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Source of Support: None, Conflict of Interest: None