Fracturas costales y hemorragia suprarrenal secundarias a una distocia de hombros / Rib fractures and adrenal haemorrhage secondary to shoulder dystocia

Presentamos el caso de un varón recién nacido a término, de parto cefálico-vaginal, que sufrió una distocia de hombros y pesó al nacer 3.950 g. Precisó reanimación superficial. El test de Apgar era de 8/9 al minuto y a los 5 minutos, respectivamente. El paciente ingresó en el servicio de neonatología, y a las 24 horas de vida sufrió un empeoramiento del estado general y, sobre todo, se constataba un dolor en el hemitórax derecho con la manipulación. En la radiografía de tórax se detectaron varias fracturas costales, y en la ecografía abdominal una hemorragia suprarrenal derecha. Con tratamiento postural y analgésicos, la evolución de ambas lesiones fue favorable, por lo que el paciente fue dado de alta tras 23 días de ingreso hospitalario. La distocia de hombros, determinada por la macrosomía, es la causa tanto de las fracturas costales como de la hemorragia suprarrenal derecha(AU)

We present the case of a newborn male child, born at term by cephalic-vaginal delivery, who suffered a shoulder dystocia and who at birth weighed 3,950 g. He required superficial resuscitation. The Apgar scores were 8/9 at one minute and at 5minutes, respectively. The patient was admitted to the neonatology service, and at the age of 24 hours his general status deteriorated and, above all, a pain was discovered in the right hemithorax upon manipulation. On the chest X-ray several rib fractures were detected, and on the abdominal ultrasound aright adrenal haemorrhage was detected. With postural treatment and analgesics both injuries evolved favourably, so the patient was discharged after a hospitalisation of 23 days. The shoulder dystocia, determined by the macrosomia, is the cause of both of the rib fractures as well as of the right adrenal haemorrhage(AU)

Fractura de clavícula en recién nacidos: factores de riesgo y morbilidad asociada / Clavicle fracture in newborns: risk factors and associated morbidities

Introducción: La fractura de clavícula es el traumatismo obstétrico óseo más frecuente en el recién nacido; se asocia a partos con distocia de hombros y a múltiples factores biomédicos relacionados. Objetivo: Analizar los factores de riesgo y morbilidad asociada con la fractura de clavícula en el recién nacido de parto normal. Pacientes y método: Estudio retrospectivo, tipo caso control, realizado en el Hospital Herminda Martín de Chillán (Chile), entre los meses de enero a junio de 2004. El grupo de estudio estuvo constituido por el total de recién nacidos con fractura de clavícula (44 casos), el grupo control se constituyó en razón de 1:2, que correspondió a los 2 partos vaginales siguientes al caso estudio (88 casos). Resultados: La incidencia fue del 4,1 por ciento; resultaron estadísticamente significativos con la presencia de fractura de clavícula el período de dilatación y expulsivo en primíparas, el peso y talla del recién nacido y la presencia de complicaciones durante el parto, como distocia de hombros (el 9,1 frente al 2,3 por ciento), el descontrol materno (el 6,8 frente al 1,1 por ciento) y laterocidencia de mano, que sólo se presentó en el grupo estudio (6,8 por ciento). Conclusiones: La fractura de clavícula en el recién nacido se asocia principalmente a factores del trabajo de parto y expulsivo

Introduction: Clavicle fractures are caused by injury during the birth process. It is associated to childbirth with difficulty in the exit of shoulders and to multiple related biomedical factors. Objective: To evaluate risk factors and associated morbidities the clavicle facture in newborn of normal childbirth. Patients and method: Retropective study, type case control in the Hospital Herminda Martín, Chillán (Chile), January to June of 2004. The group study was constituted by 44 cases of newborn with clavicle fracture, the group control constituted itself in regard to 1:2, both corresponded to following vaginal childbirths to the case study (88 cases). Results: The incidence was of 4.1 percents, were statistically significant with the time of dilatation and expulsive in primiparas, weight and size of the newborns and presence of complications in the attention of the childbirth, shoulder dystocia (9.1 percents versus 2.3 percents), maternal uncontrol (6.8 percents versus 1.1 percents) and hand-dystocia (6.8 percents). Conclusions: Clavicle fracture in newborn is associated to factors of the normal labor and delivery

Análisis de operación de cesárea y su indicación en Hospital Hanga Roa: Isla de Pascua entre 1996-2000 / Analysis of the cesarean section and their indication of the hospital Hanga Roa, Isla de Pascua in the period 1996-2000

La operación cesárea ha tenido un incremento constante en sus cifras desde la década de los 60, llegando Chile a ser el país con cifras más elevadas a nivel latinoamericano. Como parte del territorio chileno se encuentra la Isla de Pascua, que presenta una situación particular debido a su lejanía geográfica y a que el hospital está a cargo de médicos generales. Es por eso que se ha querido analizar las tasas de cesárea y sus indicaciones en el período 1996-2000, para dar una visión general de cómo se comporta esta frecuente cirugía en un lugar aislado de las redes de atención y la tecnología.

Parto instrumentado en la distocia de rotación: resultados materno-perinatales (1997-2002) / Instrumental delivery in rotation dystocia: maternal and perinatal results (1997-2002)

Fueron estudiados 912 casos de distocia de rotación, en el período comprendido entre enero del 1997 a diciembre de 2002, en el hospital materno América Arias. A las pacientes se les aplicó al menos uno de los instrumentos objeto de análisis, que fueron diseñados para dar solución a esta distocia del trabajo de parto (fórceps, espátulas y rotaxial).Se encontró esta anomalía del período expulsivo en 4,6 por ciento de los partos ocurridos en el período estudiado, siendo el forceps, el más utilizado (64,6 por ciento) seguido por las espátulas de Thierry (22,8 por ciento) y por último en orden de frecuencia el rotaxial (12,6 por ciento). Se pudieron observar diferencias en cuanto a la morbilidad materna, dadas por las lesiones del canal blando del parto. El rotaxial resultó el más inocuo pues cumple su función de lograr la rotación, pero no completa la extracción fetal(AU)

[Analysis of risk factors for perinatal brachial plexus palsy]. / Analiza czynników ryzyka okoloporodowych uszkodzen splotu ramiennego.

OBJECTIVES AND DESIGN: Risk factors of obstetrical brachial plexus palsy include: (1) large birth weight, (2) shoulder dystocia and prolonged second stage of labour, (3) instrumental vaginal delivery (forceps delivery, vacuum extraction), (4) diabetes mellitus and mother's obesity, (5) breech presentation, (6) delivery and infant with obstetrical brachial plexus palsy in antecedent delivery. The purpose was analysis of the classical risk factors for brachial plexus palsy based on our own clinical material. MATERIAL AND METHODS: Clinical material consists of 83 children with obstetrical brachial plexus palsy treated at the Department of Trauma and Hand Surgery (surgically--54, conservatively--29). Control group consists of 56 healthy newborns. Data recorded included: birth weight, body length, head and chest circumference, Apgar test at 1 min., type of brachial palsy and side affected, type of birth, presentation, duration of delivery (II stage), age of mother, mother's diseases, parity. RESULTS: The infants treated surgically have had a significantly higher birth weight, body height, head and chest circumference, in compression with control group and group treated conservatively. The differences were statistically important. Shoulder dystocia occurred in 32.9% of all vaginal delivery. Instrumental vaginal delivery was observed in 11.3% and breech presentation in 4.9% cases. There were no incidences of obstetrical brachial plexus palsy recurrence. Diabetes mellitus and mother's obesity was found in 3 cases. CONCLUSIONS: (1) Fetal macrosomia is the important risk factor of the obstetrical brachial plexus palsy. (2) Obstetrical brachial plexus palsy may occur also in the absence of the classical risk factors.

La cesárea / Caesarean section

En los últimos años estamos viviendo un aumento en la tasa de cesáreas. Por ello realizamos una valoracion de suó distintas indicaciones médicas y paramédicas con el fin de intentar acercarnos a tomar las decisiones que supongan un mayor beneficio materno-fetal. La cesárea a demanda supone uno de los aspectos más polémicos en este momento

In the past 20 years we are attending to a continuous increase in the rate of caesarean section. Because of this we try to analize the different clinical and non clinical indications for caesarean section in order to decide the best for mother and fetus. Moreover we discuss the actual controversy of caesarean section “on maternal request”

Otras maniobras obstétricas. La episiotomía. La versión. Las maniobras para la resolución de la distocia de hombros / Other obstetrical maneuvers. Episiotomy, version and shoulder dystocia maneuvers

Se realiza una revisión bibliográfica de la episiotomía, la versión y las maniobras para la resolución de la distocia de hombros. La episiotomía es la operación obstétrica realizada con más frecuencia en nuestro país. Hay muchos centros en los que se utiliza de forma rutinaria, fundamentalmente en primíparas. La evidencia científica disponible demuestra que la episiotomía sistemática no presenta ventajas ni para el feto ni para la madre, comparada con su empleo en casos seleccionados. La versión es una técnica en auge. Debido al cambio de actitud con respecto al tratamiento del parto de nalgas, con la recomendación avalada por publicaciones recientes para que sea atendido mediante cesárea, la única manera de conseguir un parto vaginal en estos casos es mediante la versión externa. La literatura demuestra que es una técnica segura y eficaz en un alto porcentaje de los casos, recomendando aumentar su empleo. La distocia de hombros es una complicación poco frecuente, pero que puede tener consecuencias muy lesivas tanto para la madre como fundamentalmente para el recién nacido. Es difícil obtener publicaciones con nivel de evidencia científica suficiente para extraer conclusiones sobre su adecuada resolución, por presentarse de forma infrecuente e impredecible. Hay que tratar de evitarla, valorando los factores de riesgo. En caso de presentarse, la maniobra más recomendada es la de Mc Roberts

We present a bibliographic rewiev about the episiotomy, the versión maneuver and the management of shoulder dystocia. Episiotomy is the most frequent obstetrical procedure used in our country. There are many medical centres in which episiotomy is applied as a routine technique in primiparous women. Scientific studies don not show more advantages for mother and infant when episiotomy is used in comparision with selected cases of pregnancy outcome. Version maneuver is an increasing procedure. It is due to the new accepted recomendation for breech presentation of performing cesarean section. Teherefore, the unique way of vaginal delivery in those cases is the version maneuver. A great number of papers have demonstrated a high safety and effectiveness of versión maneuver, recommending to increase its use. Shoulder dystocia is an unfrequent obstetrical complication, but with serious consequences for neonates and mothers. There are few papers about shoulder dystocia to obtain strong conclusions in the use of the different shoulder dystocia maneuvers. In general, it is recommended to avoid shoulder dystocia in those cases with risk factors. But when it happens, the Mc Roberts maneuver is the most safety and successfully

Brachial plexus injuries and shoulder dystocia: medico-legal commentary and implications.

Brachial plexus injuries may occur in association with or without recognised shoulder dystocia. Until recently many medico-legal experts argued that these injuries resulted from the negligent use of excessive or misdirected traction. These experts did not accept that the natural forces of labour could cause the injury. In cases of recognised shoulder dystocia, modern obstetric practice has recognised the importance of correct maternal positioning and the need to avoid excessive or misdirected traction, also the importance of not applying a rotational force to the fetal head. Informed practice and the increased use of caesarean section has not reduced the number of brachial plexus injuries. Judges in two recent trials found that the natural forces of labour were the cause of the injury and that the birth assistants had not caused the damage. This has important implications for medical note writing, teachers and risk managers, medico-legal experts and lawyers.

The negative birth experience of prolonged labour: a case-referent study.

AIMS: This study aimed to analyse and describe women's different perceptions and experiences of childbirth following prolonged or normal labour. BACKGROUND: In clinical practice prolonged labour, or dystocia, is a common delivery complication often causing a negative birth experience. METHOD: Women giving singleton live birth to their first child with spontaneous labour after more than 37 completed weeks' pregnancy at three hospitals in northern Sweden were recruited to a case-referent study. Cases (n = 84) were women following a prolonged labour with assisted vaginal or abdominal delivery, and referents (n = 171) delivered following a normal labour. Participants completed a questionnaire that investigated childbirth experiences, previous family relationships and childhood experiences. RESULTS: Women with prolonged labour had a negative childbirth experience more often (34%) than did women who had a normal labour (4%) (P < 0.05). Cases agreed significantly more than the referents with the statement, 'Pain relief during the delivery saved me' (OR 4.5, 95% CI: 1.9-11.1) and 'My difficulties during the delivery will mark me for life' (OR 12.4, 95% CI: 4.4-35.9). There were no differences between the cases and referents regarding perceived experience of professional or social support. RELEVANCE TO CLINICAL PRACTICE: To improve care, midwives and doctors can alleviate pain and relieve the negativity and difficulty associated with the experience of prolonged labour from the perspective of the woman giving birth.

[Obstetrical brachial plexus palsy--etiopathogenesis, risk factors, prevention, prognosis]. / Okoloporodowe uszkodzenia splotu ramiennego--etiologia, czynniki ryzyka, mozliwosci zapobiegania, rokowanie.

Obstetrical brachial plexus palsy (OBP) complicates a small proportion of births. The incidence is believed to be 0.35 to 5 cases per 1000 live births. Risk factors of OBP included: 1/ large birth weight, 2/ shoulder dystocia and prolonged second stage of labour , 3/ instrumental vaginal delivery (forceps delivery, vacuum extraction), 4/ diabetes mellitus and mother's obesity, 5/ breech presentation, 6/ delivery an infant with OBP in an antecedent delivery. Historically, the cause of OBP was excessive lateral traction applied to the fetal head at delivery, in association with anterior shoulder dystocia. Not all cases of brachial plexus palsy are attributable to traction. Brachial plexus injury may be occurring in the absence of shoulder dystocia, in the posterior arm of infants with anterior shoulder dystocia and can be associated with cesarean delivery. Intrauterine factors may play some role in the etiology of the OBP. Many strategies have been proposed to prevent the occurrence of OBP--control of the birth weight, induction of labour, cesarean delivery, intensified management of gestational diabetes. About 10-20% of patients with injuries of the brachial plexus require surgical intervention for optimal results.

A multicenter randomized controlled trial comparing patient-controlled epidural with intravenous analgesia for pain relief in labor.

In this multicenter, randomized, controlled trial, we sought to determine whether patient-controlled epidural analgesia (PCEA) for labor affected the incidence of cesarean delivery when compared with patient-controlled IV opioid analgesia (PCIA). Healthy, term nulliparous patients in 4 Canadian institutions were randomly assigned to receive PCIA with fentanyl (n = 118) or PCEA with 0.08% bupivacaine and fentanyl 1.6 microg/mL (n = 124). There was no difference in the incidence of cesarean delivery-10.2% (12 of 118) versus 9.7% (12 of 124)-or instrumental vaginal delivery-21.2% (25 of 118) versus 29% (36 of 124)-between groups. The duration of the second stage of labor was increased in the PCEA group by a median of 23 min (P = 0.02). Fifty-one patients (43%) in the PCIA group received epidural analgesia: 39 (33%) because of inadequate pain relief and 12 (10%) to facilitate operative delivery. Patients in the PCIA group required more antiemetic therapy (17% versus 6.4%; P = 0.01) and had more sedation (39% versus 5%; P < 0.001). Maternal mean pain and satisfaction with analgesia scores were better in the PCEA group (P < 0.001 and P = 0.02, respectively). More neonates in the PCIA group required active resuscitation (52% versus 31%; P = 0.001) and naloxone (17% versus 3%; P < 0.001). These observations support the hypothesis that PCEA does not result in an increased incidence of obstetrical intervention compared with PCIA. PCEA provides superior analgesia and less maternal and neonatal sedation compared with PCIA.

Randomized trial of McRoberts versus lithotomy positioning to decrease the force that is applied to the fetus during delivery.

OBJECTIVE: In an effort to reduce shoulder dystocia incidence and morbidity, some obstetricians use prophylactic maternal hip hyperflexion (McRoberts maneuver), with the hope of facilitating delivery and decreasing the traction needed for delivery. The objective of this study was to evaluate whether the delivery force is reduced with the prophylactic McRoberts maneuver in a prospective, objective manner. STUDY DESIGN: Between April 2002 and July 2003, we randomly assigned multiparous women with term, cephalic singleton gestations to delivery in the lithotomy or McRoberts position. A single physician used a force-measuring system that consisted of a custom glove with force sensors to record the amount of force that was exerted on the fetal head. The primary outcomes of the study were peak force (pounds; highest force needed to accomplish entire delivery), peak force for delivery of anterior shoulder (pounds), and peak force rate (pounds per second; the duration required to reach the peak force). RESULTS: The peak force was not different between the patients in the lithotomy position (n=13) versus the McRoberts position (n=14; 7.2 +/- 0.8 lbs vs 8.0 +/- 0.7 lbs; P = .5). The peak force for delivery of the anterior shoulder (6.7 +/- 0.8 lbs vs 7.1 +/- 0.7 lbs; P = .7) and peak force rate (32.3 +/- 7.0 lbs/sec vs 29.1 +/- 3.5 lbs/sec; P = .7) were not different between the patients in the lithotomy position versus the McRoberts position, respectively. There was no difference between the groups for gestational age, birth weight, incidence of diabetes mellitus, or operative vaginal delivery. The subjective degree of difficulty of the delivery correlated with the peak force (R2 = 0.53; P = .001). CONCLUSION: The use of the McRoberts maneuver before clinical diagnosis of shoulder dystocia provides no reduction in the force that is used in traction on the fetal head during vaginal delivery in multiparous patients. The acceptance of this maneuver to be used prophylactically requires re-evaluation.

Episiotomy versus fetal manipulation in managing severe shoulder dystocia: a comparison of outcomes.

OBJECTIVE: In severe shoulder dystocia, when initial maneuvers fail, either episiotomy or fetal manipulation (Rubin, Woods' screw, or posterior arm release) is recommended. We sought to compare maternal and neonatal outcomes between severe shoulder dystocia deliveries managed with episiotomy versus fetal manipulation. STUDY DESIGN: We identified severe shoulder dystocia deliveries from three databases: all shoulder dystocia deliveries (1993-2003 and 1994-1997) from two teaching institutions and litigated cases of shoulder dystocia-associated permanent brachial plexus palsy from multiple U.S. institutions. Pair-wise comparisons were made among three groups of deliveries: those managed by fetal manipulation without episiotomy (fetal manipulation-only), those managed by episiotomy without fetal manipulation (episiotomy-only), and those managed with both (episiotomy + fetal manipulation). Rates of brachial plexus palsy, neonatal depression, and anal sphincter trauma were compared among groups using chi 2 , with significance at P < .05. RESULTS: Among episiotomy-only, 13 of 22 (59.1%) sustained brachial plexus palsy, compared with 20 of 57 (35.1%) among fetal manipulation-only (P = .05). Twenty-eight of 48 (58.3%) in episiotomy + fetal manipulation had brachial plexus palsy, which did not differ from episiotomy-only (P = .95) but was higher than fetal manipulation-only (P = .02), suggesting that the addition of episiotomy conferred no benefit in averting neonatal injury. Anal sphincter trauma was significantly more common among episiotomy-only and episiotomy + fetal manipulation, compared with fetal manipulation-only. CONCLUSION: In severe shoulder dystocia, if fetal manipulation can be performed without episiotomy, severe perineal trauma can be averted without incurring greater risk of brachial plexus palsy.

Risk factors for umbilical hernia in Holstein heifers during the first two months after birth.

OBJECTIVE: To determine risk factors associated with identification of an umbilical hernia during the first 2 months after birth in Holstein heifers. DESIGN: Case-control study. ANIMALS: 322 Holstein heifers born in a single herd (45 with an umbilical hernia and 277 without). PROCEDURE: Risk factors that were examined included sire, whether the dam had a history of umbilical hernia, milk yield, duration of gestation, whether the dam had a history of dystocia, whether the heifer had a twin, birth weight, total serum protein concentration, and whether the heifer had an umbilical infection. Logistic regression was used to analyze risk factors. RESULTS: Heifers born to sires with > or = 3 progeny with an umbilical hernia were 2.31 times as likely to develop an umbilical hernia as were heifers born to sires with < or = 2 progeny with an umbilical hernia. Heifers with umbilical infection were 5.65 times as likely to develop an umbilical hernia as were heifers without umbilical infection. CONCLUSIONS AND CLINICAL RELEVANCE: Sire and umbilical infection were associated with risk of an umbilical hernia during the first 2 months of life in Holstein heifers. Attributable proportion analysis indicated that the frequency of umbilical hernias in Holstein heifers with umbilical infection would have been reduced by 82% if umbilical infection had been prevented.

Splenic haemorrhage in a newborn as the first manifestation of wandering spleen syndrome.

Wandering spleen is an unusual condition in children and is even more rarely diagnosed in the neonatal period. A case of splenic haemorrhage after dystocic birth in a newborn is reported. Before surgery, results of imaging studies were suggestive of a ruptured spleen. On laparotomy, a big haematoma surrounding a wandering spleen was found. Haemorrhage aroused from short splenic arteria. Haemostasia and splenopexy were performed. The spleen proved later to be viable. The authors speculate that the haemorrhage was the first manifestation of the wandering spleen.

Intrapartum risk factors for permanent brachial plexus injury.

OBJECTIVE: The purpose of this study was to compare maternal, neonatal, and second stage of labor characteristics in shoulder dystocia deliveries that result in permanent brachial plexus injury with shoulder dystocia deliveries that result in no injury. STUDY DESIGN: Our cases were culled from a database of deliveries that resulted in permanent brachial plexus injuries and matched to control cases that were taken from a database of consecutive shoulder dystocia deliveries from one hospital. Deliveries that resulted in injury were excluded from the control cases; those cases with no recorded shoulder dystocia were excluded from the cases. Matching was for birth weight (+/-250 g), parity, and diabetic status. Rates of precipitous and prolonged second stage, operative delivery, neonatal depression, and average number of shoulder dystocia maneuvers used were compared between the two groups with chi(2) test, Fisher exact test, and the Student t test; a probability value of <.05 was considered significant. RESULTS: There were 80 matched patients, of which 26 patients were nulliparous and 11 patients were diabetic. Mothers of the uninjured group were younger than those of the injured group (23.7+/-6.2 years vs 27.4+/-5.1 years, P<.001). The injured group had a significantly higher rate of 5-minute Apgar scores of <7 (13.9% vs 3.8%, P=.04). Differences in maternal weight, body mass index, height, race, gestational age, average number of maneuvers, head-to-body delivery interval, operative delivery rate, prolonged second stage rate, precipitous second stage rate, and sex were not significant between groups. The rates of precipitous second stage for both groups (28.0% injured and 35.0% uninjured) were more than triple the rates of prolonged second stage (9.5% injured and 11.3% uninjured). CONCLUSION: No characteristic of second-stage of labor predicts permanent brachial plexus injury. Precipitous second stage is the most prevalent labor abnormality that is associated with shoulder dystocia.

Effect of operative vaginal delivery on the outcome of permanent brachial plexus injury.

OBJECTIVE: To evaluate whether operative vaginal delivery worsens the extent and/or degree of permanent brachial plexus injury. STUDY DESIGN: We utilized a dataset (n = 104) of vaginal deliveries resulting in permanent brachial plexus injury that ultimately underwent litigation. We excluded patients on whom neonatal injury information was incomplete (n = 5). Patients who had an operative vaginal delivery (n = 33) were compared with those who did not (n = 66) in regard to neonatal outcome and the location and extent of neurologic injury. RESULTS: The 2 classes were similar in demographic and obstetric variables. There were no differences in rates of 5-minute Apgar scores < 7 (17.9%, or 5/28, vs. 5.2%, or 3/57, P = .1), complete neurologic injury to the brachial plexus (C5-T1) (39%, or 13/33, vs. 38%, or 25/66; P = 1.0) or avulsion of the nerve roots (44%, or 12/27, vs. 36%, or 18/50; P = .5) between those with operative or spontaneous vaginal delivery. CONCLUSION: Operative vaginal delivery did not increase the severity of impairment in a dataset of deliveries resulting in permanent brachial plexus injury.

Uterine rupture: risk factors and pregnancy outcome.

OBJECTIVES: This study aimed at determining risk factors and pregnancy outcome in women with uterine rupture. STUDY DESIGN: We conducted a population-based study, comparing all singleton deliveries with and without uterine rupture between 1988 and 1999. RESULTS: Uterus rupture occurred in 0.035% (n=42) of all deliveries included in the study (n=117,685). Independent risk factors for uterine rupture in a multivariable analysis were as follows: previous cesarean section (odds ratio [OR]=6.0, 95% CI 3.2-11.4), malpresentation (OR=5.4, 95% CI 2.7-10.5), and dystocia during the second stage of labor (OR=13.7, 95% CI 6.4-29.3). Women with uterine rupture had more episodes of postpartum hemorrhage (50.0% vs 0.4%, P<.01), received more packed cell transfusions (54.8% vs 1.5%, P<.01), and required more hysterectomies (26.2% vs 0.04%, P<.01). Newborn infants delivered after uterine rupture were more frequently graded Apgar scores lower than 5 at 5 minutes and had higher rates of perinatal mortality when compared with those without rupture (10.3% vs 0.3%, P<.01; 19.0% vs 1.4%, P<.01, respectively). CONCLUSION: Uterine rupture, associated with previous cesarean section, malpresentation, and second-stage dystocia, is a major risk factor for maternal morbidity and neonatal mortality. Thus, a repeated cesarean delivery should be considered among parturients with a previous uterine scar, whose labor failed to progress.