uterine rupture

Why Planned attended homebirths have better outcomes than planned hospital birth for low risk pregnancy Abstract: Hospital birth has not undergone rigorous scientific scrutiny, yet is commonly believed to be safer than planned homebirth, for both high and low-risk women. A commonly promoted opinion is that there are rare complications which can arise at birth, in which the outcomes are better if you start the labor in hospital however this view is never accompanied by a list of complications. The 5 serious birth complications are Cord prolapse, Ruptured Uterus, AFE and Placental abruption (mnemonic device:C.R.A.P) and shoulder dystocia. Cord prolapse does not occur at attended vertex full term labors in the absence of vaginal exams and amniotomy. Ruptured uterus does not occur in the absence of a scarred uterus or labor augmentation. AFE appears to accompany high risk births and hospital interventions, most often labor augmentation. For the one in a million AFE at attended homebirth, the symptoms would alert the practitioner to transfer and maternal mortality would likely be averted. Complete placental abruption has never happened at an attended homebirth because it occurs with high blood pressure, placenta previa, inductions etc. and partial abruption is not a serious complication requiring emergency transfer. The outcomes of shoulder dystocia depend on the expertise of the provider although the absence of the hospital bed, epidural, and IV make it faster and easier to prevent or treat shoulder dystocia at home. Where trained and equipped birth attendants are available, and hospital transfer is closer than 45-60 minutes, a planned, attended homebirth is safer for low-risk women than a planned hospital birth because the rare complications of birth that have better outcomes in hospital occur as a result of hospital interventions such as induction, augmentation, vaginal exams, amniotomy and previous cesareans. Currently available published research suggests there is no evidence of serious complications that can occur at an attended homebirth for women with one head-down fetus, between 37-42 weeks, no high blood pressure, no previous cesareans or medical conditions that would have better outcomes if the woman started her labor in hospital. for full text: judyslome@hotmail.com Birthing in the hospital is nothing new. Women have been going to the hospital to birth their babies since the 17 th century. What's new is the concept that the hospital is the safest place to give birth. For more than 200 years, until the 1950s, hospitals were considered the most dangerous place to give birth. In fact, before hospital birth was instituted, puerperal fever, which along with postpartum hemorrhage, were the leading cause of maternal death in industrialized nations before World War II, was very rare and was prevented by proper hand washing. Traditionally, homebirth was considered the safest place for nearly all women to give birth. But starting in 1930, a few key health care improvements, including the distribution of Sulfa drugs (1930) and then Penicillin (1945) to fight infection, the introduction of Pitocin (1953) to treat postpartum hemorrhage, improved sanitary conditions and better nutrition—in particular better access to quality protein sources, well trained birth attendants and nutritional counseling—serendipitously coincided with an increase in hospital births in the US. By 1950, hospital birth in the US began to approximate the superior planned homebirth outcomes in terms of maternal mortality. From 1940-1977, maternal mortality rates in the US dropped,

O bjective: To compare the rate of uterine scar disruption after a locked versus an unlocked single-layer closure of the hysterotomy incision at a previous cesarean. Methods: A retrospective cohort study in a population where both locked and unlocked single-layer closure are commonly used. All singleton pregnancies at 24 weeks' gestation or more with a previous single cesarean were included. Rate of uterine scar disruption (complete uterine rupture and uterine scar dehiscence) were compared between women with a previous locked and those with a previous unlocked single-layer closure of the uterus. Results: Out of 388 women included in the study, 272 had a previous unlocked single-layer closure and 116 had a locked single-layer closure. We found no significant difference in the rate of uterine scar disruption between the two groups (5.9% vs 8.6%, p=0.32). Conclusion: Locking a single-layer closure was not associated with an increase rate of uterine scar disruption at the next pregnancy in our retrospective analysis. A randomized trial should be performed.

Rupture of the gravid uterus is a grave obstetric complication that is associated with high maternal and perinatal mortality rates. In Nigeria, the incidence remains high and continue to increase because of poverty, illiteracy, unavailability of manpower, poor supply of medical equipment and consumables, and dwindling health care funding. A 10-year retrospective review of all cases of ruptured uterus seen at the Obafemi Awolowo University teaching hospital complex in Ile Ife, Nigeria was conducted. A total of 61 cases of ruptured uterus from 16,683 deliveries were recorded, giving a ratio of 1 in 273. Predisposing or aetiological factors for rupture were: prolonged labour (91.8 percent), grand multiparity (50.8 percent), injudicious use of oxytocin (41.0 percent), uterine scar (26.2 percent), obstetric manipulation (4.9 percent) and abnormal lie (14.8 percent). Fifty-six patients had surgery, of which 14 (25.0 percent) had total abdominal hysterectomy, 16 (28.6 percent) had subtotal...

Haverkamp A. Midtrimester hemoperitoneum caused by placenta percreta in association with elevated maternal serum alpha-fetoprotein level. Am J Obstet Gynecol 1994;171:565-6. 5. Ophir E, Tendler R, Odeh M, Khoury S, Oettinger M. Creatinine kinase as a biochemical marker in diagnosis of placenta increta and percreta. Am J Obstet Gynecol 1999; 180:1039 -40. 6. Hudon L, Belfort M, Broome D. Diagnosis and manage-ment of placenta percreta: A review. Obstet Gynecol Surv 1998;53:509 -17. 7. Yeshaya A, Ofer L, Sorina G-G, Ori S, Yoram D. Conservative surgical management of acute abdomen caused by placenta percreta in the second trimester. Am J Obstet Gynecol 1994;170:1388 -9. 8. Cox S, Carpenter R, Cotton D. Placenta percreta: Ultrasound diagnosis and conservative management. Obstet Gynecol 1988;71:454 -65.

Despite a significant decrease in maternal mortality in the last decade, Rwanda needs further progress in order to achieve Sustainable Development Goals (SDG)3 which addresses among others maternal mortality. Analysis of severe maternal outcomes (SMO) was performed to identify their characteristics, causes and contributory factors, using standard indicators for quality of care. A prospective case-control study was conducted for which data were collected between November 2015 and April 2016 in four rural district hospitals. The occurrence of SMO with near miss incidence ratios was established, followed by an analysis of the characteristics, clinical outcomes, causes and contributory factors. The SMO incidence ratio was 38.4 per 1000 live births (95% CI 33.4-43.4) and the maternal near-miss incidence ratio was 36 per 1000 live births (95% CI 31.1-40.9). The leading causes of SMO were postpartum haemorrhage (23.4%), uterine rupture (22.9%), abortion related complications (16.8%), malar...

Anhydramnios is a rather common ultrasound finding, usually caused by ruptured membranes, placental dysfunction, or impaired fetal renal function. We present a case of anhydramnios, resulting from the perforation of a fetal leg through the uterine wall. Neonatal death occurred caused by severe lung hypoplasia. The absence of clinical symptoms strongly suggests a preexisting weak spot in the uterine wall, presumably resulting from an unrecognized perforation at a previous curettage procedure.

Background: Uterine rupture is a rare but fatal complication of pregnancy, which should be diagnosed and treated promptly. Majority of rupture occur during labor in scarred uterus, though very rare, uterine rupture may also occur antepartum. Case Report: A 32-year-old woman presented with spontaneous antepartum posterior wall uterine rupture with an unknown pregnancy, complaining with abdominal pain and impaired consciousness. At physical examination, she had a firm fullness at abdomen. The ultrasound was inconclusive due to intra-abdominal gas, except for pelvic free fluid, and computed tomography scans showed an intra-abdominal dead fetus. Surgery revealed a wide perforation at the posterior wall of uterus and massive hemoperitoneum, in addition to a dead fetus. The patient underwent hysterectomy due to poor tissue quality and extensive perforation. She made an uneventful recovery and was discharged at the end of 2 week. Conclusion: Correct clinical history plays a major role in diagnosis. An enlarged uterus in a patient with previous cesarean section should alert the radiologist for uterine rupture. Whenever ultrasound imaging is insufficient to clarify the clinical manifestation, further imaging should be obtained.

Purpose To review the incidence, trends, risk factors, indications for, and complications associated with cesarean hysterectomy (CH) in our institution. Materials and methods Retrospective study of 158 women who had CH at the Detroit Medical Center during a 17 period. Results During the study period, 158 of 202,356 deliveries were CH, giving an overall incidence of 0.78 per 1,000 deliveries. Of the 158 cases, 14 were elective while 144 were emergently performed due to complications encountered at cesarean section. Analysis of the eligible 144 cases showed that the commonest risk factors were previous cesarean delivery (76%) and placenta previa (35%). Abnormal placenta adherence was the indication for CH in 50.7%, followed by uterine atony in 34.7% and uterine rupture in 16.7% of the cases. Febrile morbidity (44.4%) and disseminated intravascular coagulopathy (22.9%) were the most common postoperative complications. Most compli-cations occurred in patients with parity greater than two. Compared to the last decade, CH performed more recently were less likely to be complicated by bowel injury or disseminated intravascular coagulopathy. Conclusion Morbidly adherent placenta has replaced uterine atony as the leading indication for emergent CH in our institution. High parity remains a risk factor for complications; however, we recorded a reduction in bowel injury and disseminated intravascular coagulopathy in recent years.

Obstetric performance of 1847 women with previous cesarean section (CS) during the years 1983 and 1984 were studied. Vaginal birth after cesarean section (VBAC) was attempted in 94% of females with one previous CS, 4% in those with two previous CS, and one among the 70patients with three or more previous CS. VBAC was achieved in 51% of those with one previous CS. It was successful in 60% of parturients with CS for non-recurrent causes, 36% of CS for cephalopelvic disproportion (CPD) and in 64% of those with a prior vaginal delivery. Uterine scar dehiscence was found in 0.9% of all patients with a previous CS. A failed attempt with Ventouse to achieve VBAC caused maximum maternal and perinatal morbidity.

But.-Évaluer les bénéfices et risques de l'induction du travail en cas d'utérus cicatriciel. Définir les modalités de conduite et de surveillance du travail en cas de tentative de voie basse sur utérus cicatriciel. Matériel et méthodes.-Recherche bibliographique à partie de la base de données Medline ® et de la Cochrane Database Library ®. Consultation des recommandations des sociétés savantes de gynécologie obstétrique internationales. Résultats.-Le déclenchement du travail augmente le risque de rupture utérine qui peut être estimé à 1 % en cas d'utilisation de l'ocytocine et 2 % en cas d'utilisation des prostaglandines vaginales (NP2). Les méthodes mécaniques ont été insuffisamment étudiées. Le misoprostol semble augmenter de façon importante le risque de rupture (NP3). La mise en place systématique d'une tocométrie interne ne permet pas de prévenir la rupture utérine (Avis d'expert). La direction du travail augmente modérément le risque de rupture (NP3). Le risque de rupture augmente également au-delà de trois heures de dilatation stationnaire après avoir obtenu une bonne dynamique utérine (Avis d'expert). L'analgésie péridurale doit être encouragée (Grade C). La réalisation systématique d'une révision utérine n'a pas d'intérêt (Grade C). Conclusion.-Les patientes doivent être informées des modalités de surveillance du travail en cas d'utérus cicatriciel. En cas de décision de déclenchement, la patiente devra être informée de l'indication du déclenchement et du risque augmenté de rupture utérine. Les modalités du déclenchement devront tenir compte des caractéristiques maternelles et obstétricales.

Labor induction abortion is effective throughout the second trimester. Patterns of use and gestational age limits vary by locality. Earlier gestations (typically 12 to 20 weeks) have shorter abortion times than later gestational ages, but differences in complication rates within the second trimester according to gestational age have not been demonstrated. The combination of mifepristone and misoprostol is the most effective and fastest regimen. Typically, mifepristone 200 mg is followed by use of misoprostol 24-48 h later. Ninety-five percent of abortions are complete within 24 h of misoprostol administration. Compared with misoprostol alone, the combined regimen results in a clinically significant reduction of 40% to 50% in time to abortion and can be used at all gestational ages. However, mifepristone is not widely available. Accordingly, prostaglandin analogues without mifepristone (most commonly misoprostol or gemeprost) or high-dose oxytocin are used. Misoprostol is more widely used because it is inexpensive and stable at room temperature. Misoprostol alone is best used vaginally or sublingually, and doses of 400 mcg are generally superior to 200 mcg or less. Dosing every 3 h is superior to less frequent dosing, although intervals of up to 12 h are effective when using higher doses (600 or 800 mcg) of misoprostol. Abortion rates at 24 h are approximately 80%-85%. Although gemeprost has similar outcomes as compared to misoprostol, it has higher cost, requires refrigeration, and can only be used vaginally. High-dose oxytocin can be used in circumstances when prostaglandins are not available or are contraindicated. Osmotic dilators do not shorten induction times when inserted at the same time as misoprostol; however, their use prior to induction using misoprostol has not been studied. Preprocedure-induced fetal demise has not been studied systematically for possible effects on time to abortion. While isolated case reports and retrospective reviews document uterine rupture during second-trimester induction with misoprostol, the magnitude of the risk is not known. The relationship of individual uterotonic agents to uterine rupture is not clear. Based on existing evidence, the Society of Family Planning recommends that, when labor induction abortion is performed in the second trimester, combined use of mifepristone and misoprostol is the ideal regimen to effect abortion quickly and completely. The Society of Family Planning further recommends that alternative regimens, primarily misoprostol alone, should only be used when mifepristone is not available.

A cross-sectional study of indications for cesarean deliveries in Médecins Sans Frontières facilities across 17 countries. 2015: Int J Gynaecol Obstet a b s t r a c t 1 7 Objective: To review the major indications for cesareans performed by Médecins Sans Frontières (MSF) personnel 31 from the Operational Center Brussels. Methods: A retrospective study was undertaken of all singleton cesarean 32 deliveries from 2008-2012 for which indications were recorded. Location of project, age of patient, type of anes-33 thesia, and duration of operation were also recorded. Results: A total of 14 151 singleton cesarean deliveries were 34 identified from 17 countries. Among the 15 905 indications recorded, the most common was failure to progress 35 or cephalopelvic disproportion (4822 [30.3%]), followed by previous uterine scar (2504 [15.7%]), non-reassuring 36 fetal status (2306 [14.5%]), and fetal malpresentation (1746 [11.0%]). Other indications were placenta or vasa 37 previa (794 [5.0%]), uterine rupture (676 [4.3%]), hypertensive disorders (659 [4.1%]), placental abruption 38 (520 [3.3%]), pre-rupture (450 [2.8%]), and cord prolapse (365 [2.3%]). Conclusion: Indications for cesareans in 39 MSF settings differ from those in higher-income countries. Further investigation is needed for adequate emer-40 gency obstetric care coverage. 41 46 67 reports from Tanzania [5] and Bangladesh [6] document increasing 68 numbers of cesarean deliveries in LMICs, most epidemiological analyses 69 reveal that access to this emergency obstetric service remains inade-70 quate, with only 1%-2% of deliveries occurring by cesarean in many 71 African countries [4,7,8]. 72

Methods This was a study of 30 pregnant women who had had at least one previous Cesarean section and were between 36 and 39 weeks' gestation, with singleton pregnancies in cephalic presentation. Sonographic examinations were performed by two observers using both 4-7-MHz transabdominal and 5-8-MHz transvaginal volumetric probes. LUS measurements were performed using two-and three-dimensional ultrasound, evaluating the entire LUS thickness transabdominally and the LUS muscular thickness transvaginally. Each observer measured the LUS four times by each method. Reliability was analyzed by comparing the mean of the absolute differences, the intraclass correlation coefficients, the 95% limits of agreement and the proportion of differences < 1 mm.

Vaginal birth after caesarean section is the delivery of a baby through the vagina after a previous cesarean delivery. For this to be conducted safely and responsibly emergency obstetric care must be available. To study the different modes of delivery in Dhulikhel Hospital (DH), evaluate the frequency of attempted and successful vaginal birth after caesarean section and, in the VBAC group, to identify those factors that may influence outcome and safety. The study was a retrospective study of all women who were delivered via different routes and the subgroup who underwent attempted vaginal birth after caesarean section in DH from January 2007 to December 2009. In this study factors associated with the successful VBAC were also analyzed. During the study period a total of 4215 deliveries conducted in DH and a total of 890 lower segment caesarean sections (21.1% of all deliveries) were performed. Of the 890 caesareans performed, 743 were primary and 147 were repeat (69 were repeat elective and 78 were repeat emergency). In this period an additional 33 women with previous lower segment caesarean sections had a successful vaginal delivery. Hence 18.3% (33/180) vaginal birth after caesarean sections was conducted successfully among women with previous caesarean). The results of this study indicate that vaginal birth after caesarean section is a clear feature of obstetric practice in DH. This is possible because of the vigilance in managing these women and the availability in this hospital setting of resources for immediate cesarean section.

Background Rupture of the uterus, especially in a scarred uterus, intrapartum is well known. The risk of uterine rupture in women with a previous lower segment caesarean section is 0.2-1.5%, whereas in an unscarred uterus it is extremely rare. Case Case 1 A 26-year-old woman in her third pregnancy was referred at 16 weeks from a community hospital. She had a history of uterine perforation at the fundus in her Wrst pregnancy during a dilatation and curettage requiring laparotomy and repair. In her second pregnancy, fetal death had occurred in the second trimester. She conceived subsequently and in her third pregnancy, the risk of silent rupture of uterus was explained, but the couple opted for continuation of this pregnancy. Case 2 A 25-year-old woman in her third pregnancy was referred. In her Wrst pregnancy, she had a septic abortion during the Wfth month of pregnancy. Two years later, she presented at 16 weeks gestation with a severe abdominal pain. An ultrasound/MRI revealed a uterine wall defect with an empty uterus, fetus lying outside the uterine cavity with moderate free Xuid. In her third pregnancy, 18 months later, at 10 weeks gestation an ultrasound revealed a single live intrauterine pregnancy with an indistinct thinning and sacculation of the fundo-posterior uterine wall. Conclusion With increasing caesarean rates, every obstetrician is bound to face the challenge of this life-threatening obstetric hazard and must be prepared to handle this emergency with an expeditious recourse to laparotomy.

OBJECTIVE-To examine adverse birth events on the development of cerebral palsy (CP) in California. STUDY DESIGN-A retrospective population-based study of children with CP (as of 11/31/2006), matched to their maternal/infant delivery records (1/1/1991 to 12/31/2001) was performed. Demographic data and intrapartum events were examined. Six adverse birth related events were chosen. Children without CP were controls. RESULTS-7242 children had CP (59% term) and 31.3% had one or more of the six adverse intrapartum events (12.9% in controls P< 0.0001). This held for both term (28.3% v. 12.7% controls) and preterm (36.8% v. 15.9%, controls) neonates (both P< 0.0001). Maternal (15.1% v. 6.6%) and neonatal (0.9% v, 0.1%) infection were increased in CP cases (P< 0.0001). CONCLUSION-Almost 1/3 of children with CP had at least one adverse birth-related event. Higher rates in the preterm group may partially explain the higher rates of CP in this group.

Obstructed labour with ruptured uterus is a serious obstetrical complication with a high incidence of maternal and foetal morbidity and mortality. This study was conducted to find out the incidence of uterine rupture particularly in the patients of obstructed labour (OL), foeto-maternal outcome of such patients, and its management. This two year descriptive study was conducted in the Department of Obstetrics and Gynaecology Unit-I, at Muhammad Medical College Hospital from 1st January 2007 to 31st December 2008, on 40 diagnosed cases of OL. Patients were admitted through Casualty or were admitted in ward. Patients with previous caesarean section and myomectomy were excluded. Ruptured uterus was found in 8 out of 40 patients of obstructed labour, they were relatively elder and grand-multiparous. Mean age of the patients was 36.5 years, while parity ranged between 5 and 12. Only one (12.5%) patient was primigravida with mean gestational age of 39.15 weeks. Seven (87.5%) patients had a...

A case of asymptomatic uterine fenestration in 26+3 gestational weeks in a patient who had previously undergone Caesarean section is presented. Controls were planned. In gestational week 34+1 the woman was hospitalized due to lower abdominal pain, but with otherwise normal objective parameters. Ten days later the patient had increasing pain, and a caesarean section was performed. Fenestration was confirmed. This leads to reflections on how to treat and observe such cases, and further discussion about whether early identification of risk patients by ultrasound is possible.

Objective: To examine the risks of vaginal delivery after previous cesarean and to find criteria to help decide whether a trial of labor or an elective repeat cesarean should be preferred. Methods: We evaluated 29,046 deliveries after previous cesarean registered in a pooled database of 457,825 deliveries used to assess quality control in gynecology and obstetrics departments in Switzerland. Results: Among the 17,613 trial-of-labor cases logged (attempt rate 60.64%), the success rate was 73.73% (65.56% after inducing labor and 75.06% after the spontaneous onset of labor). The following complications were significantly more frequent in the previous-cesarean group: maternal febrile episodes (relative risk [RR] 2.77; 95% confidence interval [CI] 2.52, 3.05), thromboembolic events (RR 2.81; CI 2.23, 3.55), bleeding due to placenta previa during pregnancy (RR 2.06; CI 1.70, 2.49), uterine rupture (92 cases; RR 42.18; CI 31.09, 57.24), and perinatal mortality (118 cases, including six associated with uterine rupture; RR 1.33; CI 1.10, 1.62). The postcesarean group also showed a 0.28% rate of peripartum hysterectomy (81 cases; RR 6.07; CI 4.71, 7.83). There was one maternal death in the group, compared with 14 maternal deaths in the group without previous cesarean (no statistical significance). The risk of uterine rupture for patients with previous cesareans was elevated in the trial-of-labor group compared with the group without trial of labor (RR 2.07; CI 1.29, 3.30), but all other maternal risks, including peripartum hysterectomy (RR 0.36; CI 0.23, 0.56), were lower. When comparing the women having a trial of labor, the 70 with uterine rupture more often had induced labor (24.29% compared with 13.92% in the nonrupture group; P ‫؍‬ ‫؍‬ ‫؍‬ .013), had epidural anesthesia (24.29% compared with 8.44%; P < < < .001), had an abnormal fetal heart rate tracing (32.86% compared with 8.53%; P < < < .001), and had failure to progress (21.43% compared with 7.98%; P ‫؍‬ ‫؍‬ ‫؍‬ .001). Conclusion: A history of cesarean delivery significantly elevates the risks for mother and child in future deliveries. Nonetheless, a trial of labor after previous cesarean is safe. Induction of labor, epidural anesthesia, failure to progress, and abnormal fetal heart rate pattern are all associated with failure of a trial of labor and uterine rupture.

To determine the trends, predisposing factors, maternal and fetal outcome of cases of uterine rupture managed at the University of Abuja Teaching Hospital. A retrospective review of all cases of ruptured uterus managed at the University of Abuja teaching hospital, Gwagwalada, between January 2006 and December 2010 was conducted. There were 9604 deliveries in the hospital during the period of review out of which 82 were cases ruptured uterus, giving an overall incidence of 0.85% or 1 in 117 deliveries. They were mainly women of low parity with a mean age of 31.8 years. The commonest predisposing factor was injudicious use of oxytocin occurring in 38.7% of cases and was followed closely by previous caesarean section scar (28.0%). Prolonged obstructed labour was the third commonest cause of uterine rupture (18.7%) and occurred only in the unbooked patients. There were 11 maternal deaths which gave a maternal case fatality rate of 14.7%. All the deaths occurred in women who had intrapar...

Vesicovaginal fistula is physically, socially and psychologically devastating to the women who suffer from it. The aim of this study is to create some awareness about VVF, to describe the profile of the patients, etiology, and success rate of surgery in our institute. A retrospective analysis of a total of 23 cases of vesicovaginal fistula admitted to the Department of Gynecology and Obstetrics, BPKIHS over a period of three years were included in the study. The cause of VVF in all was obstructed labor except in one, which followed abdominal hysterectomy. Twenty-three subjects underwent VVF repair, of which 14 (56.5%) had successful outcome.

A review of the literature and analysis of the National Inpatient Sample Database was performed to describe the trends in vaginal birth after cesarean availability in the United States and the factors associated with changing use. Vaginal birth after cesarean increased after the first National Institutes of Health Consensus Conference on Cesarean Childbirth in 1981. It increased from 3% to a maximum rate of 28.3% in 1996. Despite studies reporting stable success rates of approximately 70% and low complication rates (<1%), concerns about patient safety and physician liability have led to more restrictive policies and a decrease in vaginal birth after cesarean use. The current rate is approximately 8.5%, and decreased rates have been noted for all age and ethnic groups. There is decreased use of vaginal birth after cesarean as the result of concerns about patient safety and physician liability, which has resulted in decreased availability.

Background: Uterine rupture is an obstetric calamity with surgery as its management mainstay. Uterine repair without tubal ligation leaves a uterus that is more prone to repeat rupture while uterine repair with bilateral tubal ligation (BTL) or (sub)total hysterectomy predispose survivors to psychosocial problems like marital disharmony. This study aims to evaluate obstetricians' perspectives on surgical decision making in managing uterine rupture. Methods: A questionnaire-based cross-sectional study of obstetricians at the 46th annual scientific conference of Society of Gynaecology and Obstetrics of Nigeria in 2012. Data was analysed by descriptive and inferential statistics. Results: Seventy-nine out of 110 obstetricians (71.8%) responded to the survey, of which 42 (53.2%) were consultants, 60 (75.9%) practised in government hospitals and 67 (84.8%) in urban hospitals, and all respondents managed women with uterine rupture. Previous cesarean scars and injudicious use of oxytocic are the commonest predisposing causes, and uterine rupture carries very high incidences of maternal and perinatal mortality and morbidity. Uterine repair only was commonly performed by 38 (48.1%) and uterine repair with BTL or (sub) total hysterectomy by 41 (51.9%) respondents. Surgical management is guided mainly by patients' conditions and obstetricians' surgical skills. Conclusion: Obstetricians' distribution in Nigeria leaves rural settings starved of specialist for obstetric emergencies. Caesarean scars are now a rising cause of ruptures. The surgical management of uterine rupture and obstetricians' surgical preferences vary and are case scenario-dependent. Equitable redistribution of obstetricians and deployment of medical doctors to secondary hospitals in rural settings will make obstetric care more readily available and may reduce the prevalence and improve the outcome of uterine rupture. Obstetrician's surgical decision-making should be guided by the prevailing case scenario and the ultimate aim should be to avert fatality and reduce morbidity.

Uterine arteriovenous malformations (AVMs) are a rare, potentially life-threatening cause of abnormal uterine bleeding that can be acquired following uterine instrumentation. We herein report a case of acquired uterine AVM following dilatation and curettage (D&C) that was successfully treated with bilateral embolization using Gelfoam (Pfizer, New York, USA) pledgets.

Background: Maternal morbidity and mortality has been a major World Health Organization concern over the years, especially in sub-Saharan Africa. This paper reports uterine rupture with severe hypovolemic shock managed at the Douala General Hospital, Cameroon. Early clinical diagnosis is paramount to maternal survival. Case presentation: Mrs. MM aged 25 years, G3P2012, of the Bamileke tribe in Cameroon was admitted to our Department in hypovolemic shock BP = 70/40 mmHg, pulse 120 beats per minute, with altered consciousness (Glasgow Coma Scale = 13). She has a history of missed abortion at 19 weeks gestation and an attempt to evacuate the uterus with misoprostol that led to uterine rupture. She underwent a total abdominal hysterectomy and blood transfusion. Her post-operative stay in hospital was uneventful. Conclusion: Uterine rupture is a complication that can be eliminated under conditions of best obstetric practice. To attain this objective, use of misoprostol in primary health facilities should be stopped or proper management of the medication instituted. The survival of patients after uterine rupture depends on the time interval between rupture and intervention, and the availability of blood products for transfusion.

Background: Understanding the magnitude and clinical causes of maternal and perinatal mortality are basic requirements for positive change. Facility-based information offers a contextualized resource for clinical and organizational quality improvement. We describe the magnitude of institutional maternal mortality, causes of death and cause-specific case fatality rates, as well as stillbirth and pre-discharge neonatal death rates. Methods: This paper draws on secondary data from 40 low and middle income countries that conducted emergency obstetric and newborn care assessments over the last 10 years. We reviewed 6.5 million deliveries, surveyed in 15,411 facilities. Most of the data were extracted from reports and aggregated with excel. Results: Hemorrhage and hypertensive diseases contributed to about one third of institutional maternal deaths and indirect causes contributed another third (given the overrepresentation of sub-Saharan African countries with large proportions of indirect causes). The most lethal obstetric complication, across all regions, was ruptured uterus, followed by sepsis in Latin America and the Caribbean and sub-Saharan Africa. Stillbirth rates exceeded pre-discharge neonatal death rates in nearly all countries, possibly because women and their newborns were discharged soon after birth. Conclusions: To a large extent, facility-based findings mirror what population-based systematic reviews have also documented. As coverage of a skilled attendant at birth increases, proportionally more deaths will occur in facilities, making improvements in record-keeping and health management information systems, especially for stillbirths and early neonatal deaths, all the more critical.

The aim of this study was to determine the outcome of labour induction following a previous caesarean section. A total of 43 cases were identifi ed; 23 out of those (53.5%) achieved vaginal delivery. The remaining 20 cases (46.5%) had a repeat caesarean. A total of 25 women had Ն 1 previous vaginal deliveries and in the remaining 18, the previous caesarean was the only pregnancy carried before the current pregnancy. Out of the 23 women who successfully delivered vaginally, 16 cases (69.6%) had a history of Ն 1 previous vaginal delivery, while no such history was reported in the remaining seven cases (30.4%). The indications for a repeat caesarean were failed induction of labour in fi ve cases (25%); fetal distress in seven cases (35%); failure-to-progress in eight cases (40%). Only one case (2.3%) of uterine rupture was reported. In conclusion, labour induction following a previous caesarean section is an eff ective and safe intervention. Vaginal delivery can be anticipated in the majority of these women. This study emphasises the need for thorough counselling of these women regarding benefi ts and risks of induction of labour, and also highlights the necessity of shared patient-doctor decision-making.

Despite a significant decrease in maternal mortality in the last decade, Rwanda needs further progress in order to achieve Sustainable Development Goals (SDG)3 which addresses among others maternal mortality. Analysis of severe maternal outcomes (SMO) was performed to identify their characteristics, causes and contributory factors, using standard indicators for quality of care. A prospective case-control study was conducted for which data were collected between November 2015 and April 2016 in four rural district hospitals. The occurrence of SMO with near miss incidence ratios was established, followed by an analysis of the characteristics, clinical outcomes, causes and contributory factors. The SMO incidence ratio was 38.4 per 1000 live births (95% CI 33.4-43.4) and the maternal near-miss incidence ratio was 36 per 1000 live births (95% CI 31.1-40.9). The leading causes of SMO were postpartum haemorrhage (23.4%), uterine rupture (22.9%), abortion related complications (16.8%), malar...

To determine the trends, predisposing factors, maternal and fetal outcome of cases of uterine rupture managed at the University of Abuja Teaching Hospital. A retrospective review of all cases of ruptured uterus managed at the University of Abuja teaching hospital, Gwagwalada, between January 2006 and December 2010 was conducted. There were 9604 deliveries in the hospital during the period of review out of which 82 were cases ruptured uterus, giving an overall incidence of 0.85% or 1 in 117 deliveries. They were mainly women of low parity with a mean age of 31.8 years. The commonest predisposing factor was injudicious use of oxytocin occurring in 38.7% of cases and was followed closely by previous caesarean section scar (28.0%). Prolonged obstructed labour was the third commonest cause of uterine rupture (18.7%) and occurred only in the unbooked patients. There were 11 maternal deaths which gave a maternal case fatality rate of 14.7%. All the deaths occurred in women who had intrapar...

Objective: This study was undertaken to compare clinical outcomes in women with 1 versus 2 prior cesarean deliveries who attempt vaginal birth after cesarean delivery (VBAC) and also to compare clinical outcomes of women with 2 prior cesarean deliveries who attempt VBAC or opt for a repeat cesarean delivery. Study design: We performed a secondary analysis of a retrospective cohort study, in which the medical records of more than 25,000 women with a prior cesarean delivery from 16 community and tertiary care hospitals were reviewed by trained nurse abstractors. Information on demographics, obstetric history, medical and social history, and the outcomes of the index pregnancy was obtained. Comparisons of obstetric outcomes were made between women with 1 versus 2 prior cesarean deliveries, and also between women with 2 prior cesarean deliveries who opt for VBAC attempt versus elective repeat cesarean delivery. Both bivariate and multivariate techniques were used for these comparisons. Results: The records of 20,175 women with one previous cesarean section and 3,970 with 2 prior cesarean sections were reviewed. The rate of VBAC success was similar in women with a single prior cesarean delivery (75.5%) compared with those with 2 prior cesarean deliveries (74.6%), though the odds of major morbidity were higher in those with 2 prior cesarean deliveries (adjusted odd ratio[OR] = 1.61 95% CI 1.11-2.33). Among women with 2 prior cesarean deliveries, those who opt for a VBAC attempt had higher odds of major complications compared with those who opt for elective repeat cesarean delivery (adjusted OR = 2.26, 95% CI 1.17-4.37). Conclusion: The likelihood of major complications is higher with a VBAC attempt in women with 2 prior cesarean deliveries compared with those with a single prior cesarean delivery. In women with 2 prior cesarean deliveries, while major complications are increased in those who

To determine the factors associated with an increased risk of perinatal death related to uterine rupture during attempted vaginal birth after caesarean section. Design Population based retrospective cohort study. Setting Data from the linked Scottish Morbidity Record and Stillbirth and Infant Death Survey of births in Scotland, 1985-98. Participants All women with one previous caesarean delivery who gave birth to a singleton infant at term by a means other than planned repeat caesarean section (n = 35 854). Main outcome measures All intrapartum uterine rupture and uterine rupture resulting in perinatal death (that is, death of the fetus or neonate). Results The overall proportion of vaginal births was 74.2% and of uterine rupture was 0.35%. The risk of intrapartum uterine rupture was higher among women who had not previously given birth vaginally (adjusted odds ratio 2.5, 95% confidence interval 1.6 to 3.9, P < 0.001) and those whose labour was induced with prostaglandin (2.9, 2.0 to 4.3, P < 0.001). Both factors were also associated with an increased risk of perinatal death due to uterine rupture. Delivery in a hospital with < 3000 births a year did not increase the overall risk of uterine rupture (1.1, 0.8 to 1.5, P = 0.67). However, the risk of perinatal death due to uterine rupture was significantly higher in hospitals with < 3000 births a year (one per 1300 births) than in hospitals with ≥ 3000 births a year (one per 4700; 3.4, 1.0 to 14.3, P = 0.04). Conclusion Women who have not previously given birth vaginally and those whose labour is induced with prostaglandin are at increased risk of uterine rupture when attempting vaginal birth after caesarean section. The risk of consequent death of the infant is higher in units with lower annual numbers of births.

Background: Prolonged second stage of labour is a major cause of perinatal and maternal morbidity and mortality in low-income countries. Vacuum extraction is a proven effective intervention, hardly used in Africa. Many authors and organisations recommend (re)introduction of vacuum extraction, but successful implementation has not been reported. In 2012, a program to increase the use of vacuum extraction was implemented in Mulago Hospital, Uganda. The program consisted of development of a vacuum extraction guideline, supply of equipment and training of staff. The objective of this study was to investigate the impact of the program. Methods: Audit of a quality improvement intervention with before and after measurement of outcome parameters. Setting: Mulago Hospital, the national referral hospital for Uganda with approximately 33 000 deliveries per year. It is the university teaching hospital for Makerere University and most of the countries doctors and midwives are trained here. Data was collected from hospital registers and medical files for a period of two years. Main outcome measures were vacuum extraction rate, intrapartum stillbirth, neonatal death, uterine rupture, maternal death and decision to delivery interval. Results: Mode of delivery and outcome of 12 143 deliveries before and 34 894 deliveries after implementation of the program were analysed. The vacuum extraction rate increased from 0.6-2.4 % of deliveries (p < 0.01) and was still rising after 18 months. There was a decline in intrapartum stillbirths from 34 to 26 per 1000 births (-23.6 %, p < 0.01) and women with uterine rupture from 1.1-0.8 per 100 births (-25.5 %, p < 0.01). Decision to delivery interval for vacuum extraction was four hours shorter than for caesarean section. Conclusions: A program to increase the use of vacuum extraction was successful in a high-volume university hospital in sub-Saharan Africa. The use of vacuum extraction increased. An association with improved maternal and perinatal outcome is strongly suggested. We recommend broad implementation of vacuum extraction, whereby university hospitals like Mulago Hospital can play an important role.To support implementation, we recommend further research into outcome of vacuum extraction and into vacuum extraction devices for lowincome countries. Such studies are now in progress at Mulago Hospital.

Objective-To determine outcome after medical or surgical treatment of postpartum mares with confirmed or presumptive uterine tears. Study Design-Case series. Methods-Postpartum mares were included if foaling had occurred within 7 days and uterine tear was confirmed surgically or, in medically treated mares, by palpation or presumed based on peritonitis. Information (age, breed; physical examination, laboratory and abdominocentesis findings; treatment, survival rates, length of hospital stay, treatments costs, and breeding performance after discharge) was obtained from the medical records (1990-2007). The influence of variables was compared between medical and surgical treatment, and between survivors and nonsurvivors. Results-For 49 mares, survival was 75%, with no significant difference between medical (11/15; 73%) or surgical (26/34; 76%) treatment. Admission variables, treatment cost, duration of hospital stay, and likelihood of foaling after discharge were not significantly different between treatment groups. Nonsurvivors were significantly more likely to have gastric reflux, higher heart rate, anion gap, lower total CO 2 , and leukocyte count, compared with survivors. Tears were significantly (P ¼ .018) more likely to occur in the right uterine horn than in other parts of the uterus. Conclusions-Uterine tears occur more commonly in the uterine horns, more so the right horn, and survival is similar with surgical or medical treatment of uterine tears in postpartum mares. Clinical Relevance-Medical treatment may be a reasonable alternative to surgical treatment for uterine tears, although the severity of tear that can resolve with medical treatment is unknown, and medical therapy can be as expensive as surgical treatment.

Background. To review the outcome of subsequent pregnancies in conservatively managed cases of uterine rupture. Methods. Charts of patients with full thickness uterine rupture in the past 25 years were reviewed and information on subsequent pregnancies was extracted from maternal and neonatal charts. Results. Thirty-seven patients with uterine rupture were identified; the uterus was scarred in 62.2%. Ruptures were repaired in 26 (70.3%). Twelve patients subsequently conceived (24 pregnancies), with recurrence in 8/24 (33.3%) pregnancies or 5/12 (41.7%) patients. Patients with recurrence had a shorter median interval from previous rupture (2 versus 5 years), a higher incidence of previous longitudinal ruptures (60.0% versus 0.0%), and the median gestational age at the preceding rupture was lower without reaching statistical significance (34 versus 38 weeks; p0/0.209). Conclusions. Longitudinal ruptures and short intervals between rupture and subsequent pregnancy predispose to recurrence of uterine rupture.

Background: Prolonged second stage of labour is a major cause of perinatal and maternal morbidity and mortality in low-income countries. Vacuum extraction is a proven effective intervention, hardly used in Africa. Many authors and organisations recommend (re)introduction of vacuum extraction, but successful implementation has not been reported. In 2012, a program to increase the use of vacuum extraction was implemented in Mulago Hospital, Uganda. The program consisted of development of a vacuum extraction guideline, supply of equipment and training of staff. The objective of this study was to investigate the impact of the program. Methods: Audit of a quality improvement intervention with before and after measurement of outcome parameters. Setting: Mulago Hospital, the national referral hospital for Uganda with approximately 33 000 deliveries per year. It is the university teaching hospital for Makerere University and most of the countries doctors and midwives are trained here. Data was collected from hospital registers and medical files for a period of two years. Main outcome measures were vacuum extraction rate, intrapartum stillbirth, neonatal death, uterine rupture, maternal death and decision to delivery interval. Results: Mode of delivery and outcome of 12 143 deliveries before and 34 894 deliveries after implementation of the program were analysed. The vacuum extraction rate increased from 0.6-2.4 % of deliveries (p < 0.01) and was still rising after 18 months. There was a decline in intrapartum stillbirths from 34 to 26 per 1000 births (-23.6 %, p < 0.01) and women with uterine rupture from 1.1-0.8 per 100 births (-25.5 %, p < 0.01). Decision to delivery interval for vacuum extraction was four hours shorter than for caesarean section. Conclusions: A program to increase the use of vacuum extraction was successful in a high-volume university hospital in sub-Saharan Africa. The use of vacuum extraction increased. An association with improved maternal and perinatal outcome is strongly suggested. We recommend broad implementation of vacuum extraction, whereby university hospitals like Mulago Hospital can play an important role.To support implementation, we recommend further research into outcome of vacuum extraction and into vacuum extraction devices for lowincome countries. Such studies are now in progress at Mulago Hospital.