|Year : 2015 | Volume
| Issue : 2 | Page : 63-65
Unilateral visual loss following assisted forceps vaginal delivery in a Nigerian neonate
Oluyemi Fasina, Mary Ogbenyi Ugalahi, Bolutife A Olusanya
Department of Ophthalmology, University College Hospital, Ibadan, Nigeria
|Date of Web Publication||22-Mar-2016|
Dr. Mary Ogbenyi Ugalahi
Department of Ophthalmology, University College Hospital, Ibadan
Source of Support: None, Conflict of Interest: None
Ocular injuries from assisted vaginal delivery have been reported in literature. Although retinal hemorrhages occur more frequently, severe sight-threatening injuries may also occur. We report a newborn baby with multiple ocular injuries and visual loss occurring after assisted forceps vaginal delivery.
Keywords: Birth trauma, forceps delivery, Nigeria, visual loss
|How to cite this article:|
Fasina O, Ugalahi MO, Olusanya BA. Unilateral visual loss following assisted forceps vaginal delivery in a Nigerian neonate. Afr J Trauma 2015;4:63-5
|How to cite this URL:|
Fasina O, Ugalahi MO, Olusanya BA. Unilateral visual loss following assisted forceps vaginal delivery in a Nigerian neonate. Afr J Trauma [serial online] 2015 [cited 2017 Dec 16];4:63-5. Available from: http://www.afrjtrauma.com/text.asp?2015/4/2/63/179222
| Introduction|| |
Ocular injuries associated with birth trauma due to assisted vaginal delivery have been documented in the literature.  Several ocular structures maybe affected; however, retinal hemorrhages have been reported to occur more frequently. , Lid lacerations,  choroidal ruptures,  descemet's membrane breaks,  descemet's membrane tears,  and traumatic optic neuropathy , are other ocular injuries associated with forceps delivery reported in the literature. However, sight-threatening injuries are not a common pattern of presentation.  We report a female neonate who sustained multiple ocular injuries with visual loss following assisted vaginal forceps delivery.
This report follows the tenets of the declaration of Helsinki, and written informed consent was obtained from the parents.
| Case Report|| |
A female neonate presented to the emergency room of the Eye Clinic, University College Hospital Ibadan, Nigeria, 20 hours post delivery on account of left ocular injury following instrumental vaginal delivery. She was a product of term gestation, delivered to a 25-year-old primiparous woman by assisted forceps vaginal delivery. The indication for the assisted vaginal forceps delivery was "poor maternal effort."
Ocular examination showed partially sutured left upper and lower eyelids lacerations, severe nonaxial proptosis of the left globe which was deviated laterally with marked limitation of adduction, disinsertion of the medial rectus muscle, conjunctiva injection, mild diffuse corneal edema, and a fixed mid-dilated pupil with a poor view of the fundus. There was no step deformity of the orbital rim, and the right globe was normal [Figure 1]a and b. A clinical diagnosis of left orbito-ocular injury with suspected traumatic optic neuropathy and medial rectus injury, secondary to instrumental vaginal delivery was made.
|Figure 1: (a) Clinical picture showing nonaxial proptosis of the left globe at presentation. (b) Clinical picture showing avulsed medial rectus muscle tendon at insertion to the globe|
Click here to view
Cranio-orbital computed tomography scan showed a nonenhancing left orbital swelling posterior to the globe, avulsed medial rectus at its insertion to the globe, which was laterally proptosed and displaced. The attachment of the optic nerve to the globe could not be delineated due to the collection around it [Figure 2].
|Figure 2: Axial scan showing left nonaxial proptosis and avulsed medial rectus muscle|
Click here to view
A protective tarsorrhaphy was applied laterally, and she was commenced on intravenous antibiotics (ceftriaxone at 80 mg/kg in two divided doses), topical steroid (Gutt Dexamethasone thrice daily) as well as antibiotic ointment (Oc Chloramphenicol nocte) to allow the edema to subside while she was planned for a detailed examination under anesthesia with orbital exploration and repair of lacerations.
Intraoperatively, the left medial rectus muscle tendon was found to have been severed from its insertion on the globe while the muscle belly had retracted into the orbit and could not be identified. The cornea edema impaired a good view of the fundus on indirect ophthalmoscopy. A maximal lateral rectus recession (11.5 mm from insertion) was performed. The lid lacerations were repaired with 6/0 vicryl suture and a lateral paramedian tarsorrhaphy was reapplied. She fared well-postoperatively and was discharged home the following day. At 4 weeks postoperative follow-up visit, there was still residual proptosis with the limitation of adduction of the globe. There was severe left visual impairment demonstrated by marked objection to occlusion of the right eye. Indirect ophthalmoscopy done under sedation revealed marked disc pallor and no retinal hemorrhages. She was continued on topical lubricants, and further follow-up visits were scheduled.
| Discussion|| |
Indications for instrumental vaginal delivery include prolonged labor, maternal distress, fetal distress, and poor maternal effort ,, as was the case in our patient. Fetal complications such as bruises and fracture of the skull following forceps delivery were noted over a 10-year period in a tertiary hospital in Nigeria.  A 3-year review of instrumental delivery compared vacuum extractor with forceps showed that fetal injury occurred more frequently with forceps delivery.  Poor handling technique and malpositioning of the forceps are factors that predispose to fetal injury.  Conversely, a retrospective study of forceps delivery at University College Hospital Ibadan, Nigeria over a 5-year period reported no fetal injury. 
Previous reviews on fetal injuries following instrumental vaginal delivery in Nigeria did not report any severe or vision threatening ocular injuries. , Similarly, a study  in Quebec reporting maternal and fetal outcome postinstrumental vaginal delivery documented no ocular injuries.
A cohort study  among a large population in the United States reported a higher incidence of birth trauma in children delivered by forceps compared to vacuum extraction. However, there was no observed difference in the incidence of ocular injuries.
Other reports ,, globally have shown that ocular injuries are more common with instrumental deliveries, although most times they are not sight-threatening and specialist care may not be required. 
Although ocular injuries may occur during nonassisted vaginal deliveries, they are usually mild. , Ocular injuries from forceps deliveries are usually due to improper placement of the forceps and may include eyelid lacerations,  cornea injuries, ,, hyphema, and posterior segment injuries such as Purtchers retinopathy  and choroidal ruptures.  These injuries are more likely to impact significantly on vision.
Our patient sustained multiple orbito-ocular injuries including eyelids lacerations, traumatic optic neuropathy, avulsion of medial rectus, and loss of vision. The extent and severity of these ophthalmic injuries differ from previous reports. ,, We did not find retinal hemorrhages in our patient 1 month after the injury, although they have been reported to be frequent following birth trauma. , It is possible that they were present at presentation but were missed due to poor fundal visualization from cornea edema.
The orbito-ocular trauma sustained in this neonate was probably due to improper application of the forceps to the fetal head. Although there is a decline in the rate of forceps vaginal delivery in Nigeria, , severe orbito-ocular injuries can occur and therefore, proper skills acquisition in the technique of vaginal forceps delivery is vital before its use. Improper application of forceps poses a great risk to the fetus.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Fleming GB. A paper on recognition and treatment of birth injuries in the newly born. Br Med J 1931;2:481-5.
Jain IS, Singh YP, Grupta SL, Gupta A. Ocular hazards during birth. J Pediatr Ophthalmol Strabismus 1980;17:14-6.
Khalil SK, Urso RG, Mintz-Hittner HA. Traumatic optic nerve injury occurring after forceps delivery of a term newborn. J AAPOS 2003;7:146-7.
Estafanous MF, Seeley M, Traboulsi EI. Choroidal rupture associated with forceps delivery. Am J Ophthalmol 2000;129:819-20.
Honig MA, Barraquer J, Perry HD, Riquelme JL, Green WR. Forceps and vacuum injuries to the cornea: Histopathologic features of twelve cases and review of the literature. Cornea 1996;15:463-72.
Agarwal S, Radhika N, Padmanabhan P. Clear cornea with large central descement membrane tears following birth trauma. Delhi J Ophthalmol 2012;23:199-201.
Osmundson G, Giangiacormo J. Traumatic optic neuropathy in a newborn. J Pediatr Ophthalmol Strabismus 1999;36:349-50.
Anate M. Instrumental (operative) vaginal deliveries: Vacuum extraction compared with forceps delivery at Ilorin University Teaching Hospital, Nigeria. West Afr J Med 1991;10:127-36.
Aimakhu CO, Olayemi O, Enabor OO, Oluyemi FA, Aimakhu VE. Forceps delivery at the University College Hospital, Ibadan, Nigeria. West Afr J Med 2003;22:222-4.
Adaji SE, Shittu SO, Sule ST. Operative vaginal deliveries in Zaria, Nigeria. Ann Afr Med 2009;8:95-9.
Ogunniyi SO, Sanusi YO, Faleyimu BL. Forceps delivery at Wesley Guild Hospital, Ilesa, Nigeria: A ten year review. West Afr J Med 1997;16:30-5.
Wen SW, Liu S, Kramer MS, Marcoux S, Ohlsson A, Sauvé R, et al.
Comparison of maternal and infant outcomes between vacuum extraction and forceps deliveries. Am J Epidemiol 2001;153:103-7.
Demissie K, Rhoads GG, Smulian JC, Balasubramanian BA, Gandhi K, Joseph KS, et al.
Operative vaginal delivery and neonatal and infant adverse outcomes: Population based retrospective analysis. BMJ 2004;329:24-9.
Johanson RB, Rice C, Doyle M, Arthur J, Anyanwu L, Ibrahim J, et al.
A randomised prospective study comparing the new vacuum extractor policy with forceps delivery. Br J Obstet Gynaecol 1993;100:524-30.
Holden R, Morsman DG, Davidek GM, O′Connor GM, Coles EC, Dawson AJ. External ocular trauma in instrumental and normal deliveries. Br J Obstet Gynaecol 1992;99:132-4.
Angell LK, Robb RM, Berson FG. Visual prognosis in patients with ruptures in Descemet′s membrane due to forceps injuries. Arch Ophthalmol 1981;99:2137-9.
[Figure 1], [Figure 2]