Spontaneous bladder rupture during labor or postpartum, although uncommon, is a surgical emergency. Creatinine and urea levels and ratio are helpful in reaching a diagnosis prior to laparotomy. Postpartum patients, especially those who have had repair of perineal laceration, should be encouraged to empty their bladder completely, and should be observed carefully for signs of urinary retention so as to avoid or reduce the risks of possible spontaneous bladder rupture. Case ReportA 30-year-old nulliparous lady with a 10-year history of primary infertility was admitted at 40 weeks' gestation for induction of labor. The indication for induction was pregestational diabetes treated with insulin therapy, at term. Cervical ripening was carried out with three doses of Prepidil (prostaglandin) gel, 0.5 mg, given six to eight hours apart. Subsequently, artificial rupture of membranes was performed and Pitocin augmentation initiated six hours after the last prostin insertion. Labor progressed satisfactorily, with the first stage lasting nine hours, and the second stage 42 minutes. During the course of labor, the patient emptied her bladder three times. Two hours prior to full dilatation, a full bladder was noted. The bladder was catheterized with a Foley's catheter and 600 mL of clear urine was obtained. The patient had a normal vaginal delivery of a live female infant weighing 3254 grams. There was a second-degree perineal tear, which was repaired. The patient was discharged home 48 hours postpartum in satisfactory condition.The patient was admitted to the emergency room 84 hours after delivery with sudden onset of severe abdominal pain, oliguria and hematuria three hours prior to admission. She gave a history of nonspecific mild abdominal pain and frequency of micturition since delivery, without vomiting or change in bowel habits. She denied any history of trauma to the abdomen or a fall at home. On examination, she was dehydrated and dyspneic. Blood pressure was 110/70, pulse 120/minute and temperature 36.6°C. She had bilateral lower limb edema, while her abdomen was markedly distended with diffuse tenderness, guarding and rebound. The uterus was difficult to palpate and the lochia was normal. The bladder was catheterized and a small amount of clear urine obtained. Urine culture grew group D Enterococcus. Ultrasound scan of the uterus suggested either retained products or blood clots within a uterus of relatively normal size.The results of blood tests are detailed in Table 1. The total WBC was 6.7 K/mm 3 , while BUN (40 mg/L) and creatinine (5 mg/L) were significantly elevated. Plain abdominal x-ray showed left subdiaphragmatic air trap. A tentative diagnosis of a ruptured viscus, probably a ruptured peptic ulcer, was made and a laparotomy was carried out. Three to four liters of serous fluid were found within the peritoneal cavity. This grew Enterococcus fecalis. There was a 5 cm laceration in the dome of the bladder. This was repaired in two layers. There was no evidence of uterine or cervical lacerations, nor of any d...

H Narchi, N Kulaylat, E Ekuma-Nkama, Clavicle Fracture and Brachial Plexus Palsy in the Newborn: Risk Factors and Outcome. 1996; 16(6): 707-710 Since first reported in 1764, brachial plexus palsy and fractured clavicle in the newborn have been the subject of many publications aiming at defining their causes and looking at their prognosis, with varied and sometimes conflicting findings. [1][2][3][4][5][6][7][8][9][10][11][12]18 We undertook this study in a primary care setting of a developing country, in a population with high parity and a high incidence of diabetes in pregnancy, aiming to determine the incidence of these injuries in infants born in our hospital, to identify possible risk factors in our population and to determine the prognosis for full recovery of affected babies. Material and MethodsThe study included all infants who were born at our medical center between January 1991 and December 1993. All neonates were examined by pediatricians soon after birth and prior to discharge home any time after the first 24 hours. Weakness of the upper extremity during examination was looked for and the type of palsy (upper or lower brachial plexus involvement) was defined; loss of continuity or tender swelling over the clavicle, presence or absence of Horner syndrome or phrenic nerve palsy were sought, and x-rays were carried out to rule out a fracture of the clavicle in all affected infants.All affected infants were regularly followed up at two weeks, one and two months, and thereafter as indicated. Some cases of fractured clavicle were diagnosed a few weeks after birth when a visible callus, often first noticed by the mother, was seen. In cases of brachial plexus palsy, parents were instructed to passively mobilize the infant's affected limb through a full range of motion several times a day. Affected infants who did not recover within six months were referred to the orthopedist or neurologist and physical therapist.Maternal and neonatal data were collected, and peripartum events were analyzed. For infants with brachial plexus palsy, the age of recovery of normal function on follow-up was sought.Data was compared between the affected population and the rest of the nonaffected infants over the same period of the study. The t-test was used to compare means and the corrected chi-squared test was used to compare proportions (Fisher's exact test for small values). Results Brachial Plexus PalsyOf the 8855 live births at our medical center during the period of the study, 37 infants were diagnosed to have brachial plexus palsy, giving an incidence of 4.17 per 1000 live births. Of these, there were 24 (64.8%) left, 13 (35.2%) right and no bilateral palsies. All were upper brachial plexus palsies (Erb's), four had associated homolateral fractured clavicle, and none had Horner syndrome or phrenic nerve palsy.There were 22 affected males (59.5%) and 15 females (40.5%). All but three infants were delivered vaginally (92%); one singleton and a set of twins were delivered by cesarean section for breech position. The average...

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