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Objective Shoulder dystocia is a dreadful complication of vaginal deliveries since it can be responsible of brachial plexus palsies and even neonatal deaths. Unlike most studies, we defined shoulder dystocia as the enclosing of fetal shoulders above the superior strait (cavity station of 1cm) and situations being resolved only by delivery of the posterior arm (Jacquemier's maneuver). The purpose of this study was to analyze cases of shoulder dystocia in terms of maternal and neonatal complications and to compare risk factors with those identified in the literature. Material and methods We conducted a retrospective study of 14 cases of severe shoulder dystocia (SSD) which occurred at our hospital between January 1995 and January 2007. TSD was diagnosed in the absence of engagement of both fetal shoulders requiring recourse to Jacquemier's maneuver for delivery. Any gestational diabetes, abnormal progression of labour, suspicion or existence of fetal macrosomia, instrumental delivery, and neonatal complications were noted. Results The incidence of SSD was around 1 per thousand. Multiparity, weight gain greater than 15kg and gestational diabetes were moderately present in our study group. Only 20% of neonates were macrosomic and 50% had a birth-weight of less than 4000g. In 80% of cases, an instrumental extraction was practised. Brachial plexus injuries affected 20% of neonates, no fracture was observed, one child died following an unresolved SSD. Conclusion This series shows that the incidence of SSD is rare and difficultly predictable even though identified risk factors exist. However, an instrumental extraction seems frequently associated with SSD and any extraction should take into account the presence of known risk factors. In spite of the severity of our cases of shoulder dystocia, complications found seemed to be similar to those observed in the literature.

Postpartum haemorrhage remains a dangerous obstetrical complication, which is the main cause of maternal mortality in developing countries. The diagnosis must be immediate and its management is both medically and surgically in life-threatening haemorrhage. We present a case of a thirty-three-year-old woman who asked a pregnancy interruption for premature rupture of membranes at 21(th) gestational week for her second pregnancy; she underwent a caesarean section at term for her first pregnancy. She delivered vaginally and developed a postpartum haemorrhage with hemorrhagic shock which was resistant to medical, surgical and radiological management. We decided to use recombinant activated factor VII (rFVIIa, NovoSeven) as a final attempt to rescue the patient. During surgery, two intravenous bolus injections (60, 120 mug/kg) were successfully given with a control of bleeding and haemoglobin. The patient developed later a splenic thrombosis that can be related to either rFVIIa or to the hypovolemic shock or to the sepsis. Recombinant activated factor VII is an interesting and promising haemostatic agent in the management of life-threatening postpartum haemorrhage unresponsive to conventional treatment.

Resume Introduction Les techniques de curage axillaire sont en constante evolution. L’apparition de la pince Ligasure Precise ® R et son cout doivent faire poser la question du benefice de son emploi par rapport aux clips chirurgicaux. Objectif Comparer l’efficacite du Ligasure ® par rapport aux clips chirurgicaux dans le curage axillaire simple ou dans l’intervention de Patey en termes de duree de drainage, de cout d’hospitalisation et de complications. Materiel et methode Etude retrospective s’etendant du 1 er janvier 2003 au 31 decembre 2004, concernant 187 patientes beneficiant d’un curage axillaire simple (100) ou d’un Patey (87), avec emploi de clips chirurgicaux ou de Ligasure et d’un drainage. Resultats L’emploi du Ligasure augmente le cout operatoire car son prix est superieur a celui d’une pince a clips avec une recharge. Le Ligasure diminue significativement la duree de drainage dans les deux groupes mais il y a significativement plus de lymphoceles dans le groupe curage. Quand on calcule le cout d’hospitalisation lie au choix de la technique d’hemostase (cout du materiel + duree de drainage X prix de la journee d’hospitalisation), on ne retrouve pas de difference significative en faveur du Ligasure. Quand on calcule le cout total d’hospitalisation tenant compte du choix de la technique d’hemostase et de la duree d’hospitalisation (cout du materiel + duree d’hospitalisation X prix de la journee d’hospitalisation), il n’y a pas de difference significative dans les deux groupes. Conclusion Cette etude compare la pince Ligasure Precise ® aux clips chirurgicaux dans le curage axillaire. Elle diminue significativement la duree de drainage mais son benefice sur le taux de lymphocele reste a demontrer. L’emploi du Ligasure ® ne diminue pas significativement le cout d’hospitalisation obligatoire.

OBJECTIVES A nonfrank breech is generally believed to be associated with abnormal labor and risk of cord prolapse. Owing to these risks, many authors consider such a presentation as a positive indication for cesarean section. The purpose of this study was to estimate the delivery characteristics of nonfrank breech with a gestational age over 37 weeks and particularities of this presentation. PATIENTS AND METHODS This retrospective study included all deliveries with a nonfrank breech presentation and a gestational age over 37 weeks over a sixteen years period in our maternity ward. A descriptive analysis of maternal, fetal and obstetrical elements was carried out. RESULTS 198 deliveries were indexed with 54% vaginal birth, regularly observed throughout the study period. Thirty percent delivered by prelabor planned cesarean section and 16% by cesarean section during labor. When a vaginal birth trial was allowed, at last 77.4% delivered by this route. Average labor time in the vaginal birth group was only 4.5 hours. Eleven cord prolapses were found (5.6%) of which more than half delivered by vaginal birth without fetal complications. Perinatal outcomes were satisfactory for the whole population, without differences between cesarean section and vaginal birth. DISCUSSION Cord prolapse is a risk of nonfrank breech presentation but abnormal labor is not more frequent than with frank breech presentations if labor is managed rigorously. More than 75% patients of the vaginal birth trial group delivered by vaginal birth with perinatal outcomes as good as the cesarean section group. Unlike traditional reports, in our study a nonfrank breech was not an unfavorable factor for vaginal birth after strict selection of vaginal birth trial candidates.

Journal de Gynecologie Obstetrique et Biologie de la Reproduction - Vol. 34 - N° 8 - p. 781-788