Major injuries to the urinary tract in association with childbirth

This retrospective study was designed to determine the incidence of major injuries to the urinary tract that occur during parturition and to assess their management. Twenty one such injuries were managed at the maternity wing of the Riyadh Medical Complex in a four-year period. They occurred during a total delivery of 48,693. This gives an incidence of major urinary trauma of 43 per 100,000 births. There were 4,622 deliveries by caesarean section, giving a section rate of 9.5%. Of ten cases of severe bladder injuries, seven occurred in association with ruptured uteri, and three at repeat caesarean sections. One case of bladder rupture involved injury to the ureters, and another was associated with vaginal laceration and traumatic vesico-vaginal fistula. All bladder injuries were discovered either on the table or soon after delivery. Ten women sustained ureteric injuries. Five injuries occurred during caesarean section, three at caesarean hysterectomies, two were avulsed from a ruptured bladder and another was ligated during repair of a deep cervical laceration. Only one case of ureteric injury was made intra-operatively. The others (90%), were discovered in the early puerperium, ranging from five to twenty one days. There was one case of rupture of a diseased kidney during labour. She presented soon after delivery and had nephrectomy. Haemorrhage was profuse in many cases and warranted hysterectomy in six cases, internal iliac artery ligation in three cases, and both procedures in one case. Assessment of viability of tissues and integrity of the ureters was made difficult by bleeding. Successful bladder repair was achieved in nine out of ten women employing limited excision of tissues and liberal drainage. Exploration and repair of ureteric injuries was preceded by a period of percutaneous nephrostomy drainage. This approach was associated with good results.