Uterine rupture and vacuum extraction

Complications of shoulder dystocia

Complications of shoulder dystocia are divided into fetal and maternal. Fetal brachial plexus injury (BPI) is the most common fetal complication occurring in 4-40% of cases. BPI has also been reported in abdominal deliveries and in deliveries not complicated by shoulder dystocia. Fractures of the fetal humerus and clavicle occur in about 10.6% of cases of shoulder dystocia and usually heal with no sequel. Hypoxic ischemic brain injury is reported in 0.5-23% of cases of shoulder dystocia. The risk correlates with the duration of head-to-body delivery and is especially increased when the duration is >5 min. Fetal death is rare and is reported in 0.4% of cases. Maternal complications of shoulder dystocia include post-partum hemorrhage, vaginal lacerations, anal tears, and uterine rupture. The psychological stress impact of shoulder dystocia is under-recognized and deserves counseling prior to home discharge.

Rupture of the uterus: a changing picture

Eighty nine cases of rupture of the gravid uterus occurring over a period of 15 years with 77,133 deliveries, were analysed. The overall incidence of ruptured uteri was 1 per 866 deliveries. The patients were divided into two groups, those with a scarred uterus (47) and those with an unscarred uterus (42). Distinct differences in terms of parity, age, aetiology and pathogenesis, the clinical picture, pathology, type of surgery and outcome were seen between the two groups. Most pronounced was the difference in symptoms and signs. Lower abdominal tenderness (38.2%), and vaginal exploration after delivery (44.6%) were the clinical hallmarks in the scarred uterus group, compared to shock (33.3%), uterine bleeding (30.9%) and severe abdominal pain (23.8%) in the unscarred group. Moreover, conservative surgery was possible in 72.3% of the scarred group against 14.3% in the other group. A maternal mortality of 5.6% and fetal mortality of 52.8% was seen. All maternal deaths and 71.4% of fetal losses occurred in the unscarred group. Fortunately, the number of ruptures clearly decreased over the study period, and furthermore the ratio between spontaneous and traumatic ruptures of an unscarred uterus and ruptures of a scarred uterus increased.