Mogućnosti upravljanja materijalnim troškovima anestezije analizom različitih anestezioloških tehnika

The must of material cost rationalization in medical practice has stimulated the authors to analyze the structure of material expenses of spinal and general anesthesia on a model of arthroscopic knee surgery. The aim was to determine whether the cost of spinal anesthesia was still lower than that of general anesthesia after the introduction of expensive atraumatic needles. In addition, we were interested in the extent to which our daily practice correlated with that in industrialized countries and what were the possibilities of cost rationalization. Using retrograde analysis of two comparable groups of 40 patients each, submitted to arthroscopic knee surgery in general or spinal anesthesia, the anesthesia material expenses were divided into variable and constant expenses that are partially common to both types and partially specific for each type of anesthesia. The sums of variable and specific expenses were compared between the two types of anesthesia, amounting to 78,26 HRK for spinal anesthesia and 115,19 HRK for general anesthesia. There were no major operative or postoperative complications in either patient group. As only 40% of the procedures were performed in spinal anesthesia, whereas the respective figure in industrialized countries exceeds 70%, there is obviously much room for savings. If the percent of the procedures performed in spinal anesthesia were increased to the feasible 60%, a saving of 1470 HRK would be achieved exclusively in knee arthroscopy surgery, considering that some 200 procedures have been performed per year.Imperativ racionalizacije materijalne potrošnje u medicinskoj praksi potaknuo je autore da na modelu artroskopske operacije koljena analiziraju strukturu materijalnih troškova spinalne i opće anestezije. Cilj je bio utvrditi je li spinalna anestezija i nakon uvođenja skupih atraumatskih igala i dalje jeftinija od opće anestezije. Zanimalo nas je kako naša dnevna praksa korelira s onom u razvijenim zemljama i koje su mogućnosti racionalizacije. Retrogradnom analizom dviju usporedivih skupina od po 40 bolesnika artroskopiranih u općoj, odnosno spinalnoj anesteziji materijalni troškovi anestezije podijeljeni su na varijabilne i stalne, od kojih je dio univerzalan za obje anestezije, a dio specifičan za svaki tip anestezije. Uspoređivane su sume varijabilnih i specifičnih troškova dvaju tipova anestezije koje za spinalnu anesteziju iznose 78,26 kn, a za opću 115,19 kn. Ni u jednoj skupini nisu zabilježene značajne operacijske ili poslijeoperacijske komplikacije. Kako je od spomenutih operacija samo 40% operirano u spinalnoj anesteziji, dok je prosjek razvijenih zemalja iznad 70%, postoji dosta prostora za uštedu. Samo na artroskopijama koljena kojih se godišnje radi oko 200 uštedjelo bi se 1470 kn kad bismo postotak operiranih u spinalnoj anesteziji podigli na realno ostvarivih 60%

Djelovanje upuhivanja ugljičnog dioksida u trbušnu šupljinu kod laparoskopskih kolecistektomija na arterijski tlak u pretilih i nepretilih bolesnika

The effect of carbon dioxide induced pneumoperitoneum and anti-Trendelenburg.s position on arterial pressure was retrospectively analyzed in 34 patients with cholelithiasis and overweight and 34 patients with cholelithiasis and normal body weight. According to general condition, all patients belonged to ASA II and ASA III groups. Upon induction in general endotracheal balanced anesthesia, patients received intermittent positive pressure ventilation. At the time of arterial pressure measurement, the following parameters were determined: respiratory volume 12 mL kg-1 body weight, respiration rate 12 breaths per minute, and inhalation to exhalation time ratio I:E=1:2. Arterial pressure was measured by automated noninvasive method in horizontal position before induction in general anesthesia (T1), upon induction in general anesthesia (T2), upon carbon dioxide inflation into abdominal cavity and anti­Trendelenburg.s position at 25° (T3), upon carbon dioxide deflation from abdominal cavity (T4), and upon completion of the operation and patient extubation (T5). Arterial pressure showed a statistically significant increase after carbon dioxide inflation and a statistically significant decrease upon carbon dioxide deflation (p<0.002 both) in both study groups. In overweight patients, both systolic and diastolic pressure increased with carbon dioxide induced pneumoperitoneum to a mean value of 167±18 mm Hg and 102±10 mm Hg, respectively, as measured at T3. In the group of patients with normal body weight, the respective pressure values were 156±19 mm Hg and 98±9 mm Hg at the same time point.Retrospektivno je analizirano djelovanje pneumoperitoneuma izazvanog ugljičnim dioksidom i anti-Trendelenburgova položaja na arterijski tlak u 34 bolesnika s kolelitijazom i prekomjernom tjelesnom težinom i 34 bolesnika s kolelitijazom i normalnom tjelesnom težinom. Svi su bolesnici prema općem stanju pripadali skupinama ASA II. i ASA III. Nakon uvoda u opću endotrahealnu balansiranu anesteziju bolesnici su umjetno ventilirani intermitentnim pozitivnim tlakom (IPPV). U vrijeme mjerenja arterijskog tlaka zabilježeni su slijedeći parametri: respiracijski volumen 12 mL kg-1 tjelesne težine, frekvencija disanja 12 udisaja u minuti, odnos udisajnog i izdisajnog vremena I:E=1:2. Arterijski tlak mjeren je automatski neinvazivno u vodoravnom položaju prije indukcije u opću anesteziju (T1), nakon uvoda u opću anesteziju (T2), nakon upuhivanja ugljičnog dioksida u trbušnu šupljinu i anti-Trendelenburgova položaja od 25o (T3), nakon ispuhivanja ugljičnog dioksida iz trbušne šupljine (T4) i nakon završetka operacije i ekstubacije bolesnika (T5). Arterijski tlak nakon upuhivanja ugljičnog dioksida u trbušnu šupljinu pokazao je statistički značajan porast (p<0,002) u obje analizirane skupine. Nakon ispuhivanja ugljičnog dioksida iz trbušne šupljine u obje analizirane skupine arterijski tlak je pokazao statistički značajan pad (p<0,002). Sistolični tlak u bolesnika s prekomjernom tjelesnom težinom je porastao nakon pneumoperitoneuma izazvanog ugljičnim dioksidom, srednja vrijednost 167±18 mm Hg (T3). Dijastolični tlak u istih bolesnika je također porastao, srednja vrijednost 102 ±10 mm Hg (T3). U skupini bolesnika normalne tjelesne težine sistolični je tlak dosegao srednju vrijednost od 156±19 mm Hg, a dijastolični 98±9 mm Hg u isto mjerno vrijeme

Palijativna skrb kao javnozdravstveni prioritet Bjelovarsko-bilogorske županije

Među brojnim zdravstvenim prioritetima u Hrvatskoj palijativna skrb, odnosno briga za oboljele u završnom stadiju neizlječive bolesti, relativno je kasno prepoznata te još uvijek nisu uspostavljeni odgovarajući institucionalni oblici takve skrbi unutar sustava javnog zdravstva. Upravo stoga Županijski tim za zdravlje BBŽ odlučio je među zdravstvene prioritete županije uvrstiti i prioritet poboljšanja skrbi za one koji boluju od neizlječivih bolesti u svom završnom stadiju. Najčešće se radi o oboljelima od zloćudnih bolesti koje, nažalost, pogađaju sve uzraste pa i djecu, ali isto tako postoje i nemaligne kronične bolesti progresivnog i fatalnog tijeka za koje nema drugih metoda liječenja osim metoda palijativne medicine (npr. amiotrofična lateralna skleroza)

PAINFUL NEUROPATHY OF THE LINGUAL NERVE – A CASE REPORT

Prikazan je slučaj šezdesetdvogodišnje bolesnice s karakterističnom kliničkom slikom kronične neuropatske orofacijalne boli u inervacijskom području lingvalnog živca. Medicinska dokumentacija pokazuje da je bolesnica tijekom šestogodišnjeg liječenja učinila brojne kliničke preglede kao i laboratorijske, ultrazvučne, radiološke, neuroradiološke i endoskopske pretrage u cilju pronalaženja mogućeg patološkog procesa u podlozi neuropatske boli. Upotrebom različitih analgetika i koanalgetika postignuta je tek djelomična analgezija. Razlozi za to mogu se pripisati nedostatku dobre komunikacije s bolesnicom, nedostatku defi niranih lako primjenjivih dijagnostičkih kriterija i metoda, nedostatnoj edukaciji o boli u dodiplomskoj nastavi, te nedostatku analgetika i koanalgetika koji bi bili učinkovitiji, sigurniji i s manje nuspojava. Još jednu od značajnih prepreka donosi i neusklađenost terapijskih algoritama i smjernica za propisivanje lijekova stručnih društava i propisa nacionalnog zavoda za zdravstveno osiguranje.In this paper, we present a case of a female 62-year-old patient with a characteristic clinical picture of chronic neuropathic orofacial pain in the lingual nerve innervation area. During six years of treatment, the patient had undergone numerous diagnostic tests, which were normal. By using different analgesics and co-analgesics, partial analgesia was achieved. The reasons for this could be the lack of appropriate communication with the patient, absence of validated and diagnostic criteria and methods easily applicable in clinical practice, insuffi cient education in pain management through undergraduate medical studies, as well as shortage in analgesics and co-analgesics that would be more effi cient, safer and with fewer side effects. Another major obstacle originates from the mismatch in therapeutic algorithms and prescribing guidelines favored by professional societies and those regulated by the National Institute of Health

COMPASSION AS THE ADDED VALUE OF HEALTH CARE

Tijekom posljednjih godina objavljen je veliki broj radova koji proučavaju učinke različitih emocionalnih interakcija između zdravstvenih djelatnika i bolesnika na ishode liječenja, cijenu ukupne skrbi te učinke na same zaposlenike u zdravstvu. Interes za ovo područje dijeli i šira javnost zbog raširenog mišljenja kako se suvremena medicina suviše depersonalizirala i distancirala od emocionalne uključenosti i suosjećajnosti. Tako nastaje nova znanstvena disciplina „kompasionomika“ (engl. Compassionomic) koja proučava mehanizme djelovanja i učinke na ishod liječenja suosjećajnog pristupa u zdravstvenoj skrbi. Istraživanja ukazuju da se pozitivni učinci na ishod bolesnika liječenih u okruženju koje njeguje kulturu suosjećajnosti i brižnosti postižu većim stupnjem povjerenja, time snažnijom mobilizacijom neuro-endokrinih i imunoloških mehanizama obrane te boljim pridržavanjem terapijskih preporuka. Time se poboljšava kvaliteta te istovremeno smanjuje cijena liječenja. Pritom je važno defi nirati pojam suosjećajnosti (engl. Compassion) koji u ovom kontekstu znači ne samo suosjećanje s patnjom (empatiju) već i spremnost aktivnog činjenja da se pacijentu pomogne. Preliminarna istraživanja pokazuju da bolji ishod liječenja kao rezultat većeg emocionalnog i stručnog angažmana zdravstvenim djelatnicima dolazi kao nagrada koja im pruža ispunjenje i time ukupno manji stres izgaranja. Ovakav koncept u mnogome je još hipotetičan. Međutim, ako su pretpostavke o „multiplicirajućem“ pozitivnom učinku suosjećajnosti na sve zainteresirane strane zdravstvenog sustava točne, tada se nameće potreba kreiranja i provedbe odgovarajućih edukacijskih programa, kako bi se osnažio terapijski pristup koji uključuje aktivnu suosjećajnost. Učinkovitost takvih programa može se mjeriti pomoću odgovarajućih alata koji mjere indikatore zadovoljstva pacijenata, zdravstvenih djelatnika i trećeg sektora kao i indikatore ishoda liječenja čime ulazimo u područje medicine utemeljene na dokazima. Suosjećajni pristup u liječenju svoje mjesto ima u svakoj medicinskoj djelatnosti, kako kurativnoj tako i palijativnoj, jer u svojoj biti njeguje holistički pristup s bolesnikom u središtu, s punom društvenom odgovornošću i visokim moralnim i etičkim standardima struke.In the past few years, there were many papers in the biomedical literature studying the effects of various emotional interactions between healthcare professionals and patients regarding treatment outcomes, total cost of care and effects on healthcare workers themselves. The interest in this area is also shared by the wider public because of the widespread belief that modern medicine has become depersonalized and distant from emotional involvement and compassion. Today, there is considerable evidence from relevant research suggesting that compassionate care brings additional value to therapeutic procedures. The study of these benefi ts, their mechanisms of action and effects on treatment outcome, as well as on healthcare providers is called ‘compassionomics’. Compassion in this context means not only emotional response to the other’s suffering, but also the willingness to help the patient. By contrast, the term empathy, often used as a synonym of the concept of compassion, refers only to understanding and being affected with the other’s suffering. Positive effects on the outcome of patients treated in an environment that fosters a culture of compassionate care are likely to be achieved through a greater degree of trust between physicians and other healthcare professionals and patients, resulting in stronger mobilization of neuroendocrine and immune defense mechanisms that can contribute to healing or alleviating the symptoms of the disease. Better compliance to therapeutic recommendations has also been noted. These favorable effects are also refl ected in reducing the length of hospital stay and frequency of readmission, thus reducing the cost of treatment. Although it may seem that relationship to patients involving more emotion and compassion would lead healthcare workers faster to burnout syndrome, preliminary research suggests the opposite. It is interpreted by the fact that better outcome of treatment as a result of the more emotional and professional involvement of healthcare professionals comes as a reward that provides fulfi llment of their human and professional mission and thus ultimately causes less pronounced burnout syndrome. All of this is the backbone of the theory of ‘multiplying’ the positive effect of compassion on all stakeholders in healthcare. If this theory is correct, then there is the need for creation and implementation of appropriate educational programs through which a therapeutic approach based on the culture of active and effective compassion will be designed. The effectiveness of such programs can be measured by appropriate tools that measure patient satisfaction, satisfaction of healthcare professionals and other interested parties. More objective indicators can be obtained by measuring the outcome of treatment, thus entering the sphere of the evidence-based medicine. In many aspects, this concept is still hypothetical and based in particular on observational studies. Compassionomics strives to make this area a subject of serious scientific expertise in which it is increasingly successful. Active compassion has its place in every medical activity, both curative and palliative, because it cares for the holistic approach with the patient in the center, with full social responsibility and high moral and ethical standards of profession. Since all healthcare systems, including ours, are constantly in the midst of increased needs and limited resources, the understanding of the multiple positive effects of compassion offers new hope for rationalization and sustainability of the healthcare system and its further development in the direction of increasing humanity

Učestalost konverzije epiduralne analgezije u regionalnu ili opću anesteziju kod carskog reza

Introduction: Epidural analgesia is acknowledged as the most common method of analgesia during labor. If emergent Caesarean section (CS) is indicated in parturient with existing labor epidural, the need for conversion from epidural analgesia to regional (RA) or general anesthesia (GA) increases accordingly. Recent guidelines suggest the rate of conversion to general anesthesia shows the quality of obstetric anesthesia care and should be under 5%. The aim: The aim of this study is to determine the conversion rate from epidural analgesia to Caesarean section anesthesia in “Sveti Duh” University Hospital Zagreb in order to enhance the quality of anesthetic care for obstetric patients. Methods: We retrospectively included in the study all parturients who received epidural labor analgesia but needed subsequent regional or general anesthesia for Caesarean section in our institution for the period of 1st January 2021 to 31st December 2021. After the data analysis on the conversion rate from epidural analgesia to Caesarean section anesthesia had been performed, we compared our data to current standards and relevant literature findings. Results: Altogether 1202 epidural catheters were placed for labor analgesia in the study period, and in 199 of these cases, the emergent Caesarean section was indicated. Epidural analgesia was converted to epidural anesthesia (EA) in 153 (76,9%) parturients, to general anesthesia in 40 (20,1%), and to spinal anesthesia (SA) in six (3%) parturients. After comparison with recommended quality standards and with the results of similar studies by other authors, our findings show a significantly higher rate of conversion from epidural analgesia to general anesthesia than has been desirable since then. Conclusion: In order to reach the required quality standards regarding the conversion rate from epidural analgesia to Caesarean section anesthesia, it is necessary to improve the organization of the work of the obstetric anesthesiology team according to the principle of subspecialization. It is imperative to implement the best clinical practice protocols for obstetric anesthesiologists, but also to enhance the communication and coordination with the obstetric team.Uvod: Epiduralna analgezija za porođaj danas je najčešća metoda analgezije tijekom porođaja. Zahvaljujući tome sve češće se javlja potreba za konverzijom iz epiduralne analgezije u regionalnu ili opću anesteziju u slučaju indikacije za hitni carski rez. Prema standardima kvalitete konverzija u opću anesteziju ne bi trebala prelaziti 5%. Cilj: Na vlastitom uzorku provesti analizu prakse konverzije epiduralne analgezije u anesteziju za carski rez retrospektivnom analizom jednogodišnjeg razdoblja kako bi se utvrdila područja za poboljšanjem u dnevnoj praksi. Ispitanici i metode: Analizirana je učestalost i konverzije epiduralne analgezije u regionalnu ili opću anesteziju u razdoblju od 01. 01. 2021. do 31. 12. 2021. Dobiveni podaci o učestalosti konverzije u pojedinu vrstu anestezije za carski rez uspoređeni su sa standardom kao i podacima sličnih istraživanja. Rezultati: Tijekom ispitivanog razdoblja stavljena su 1202 epiduralna katetera za analgeziju porođaja od čega je u 199 slučajeva nastupila indikacija za hitni carski rez te je epiduralna analgezija u 153 (76,9%) slučaja konvertirana u epiduralnu anesteziju, u 40 (20,1%) slučajeva u opću anesteziju i u 6 (3%) slučajeva u spinalnu anesteziju. Usporedba dobivenih rezultata s rezultatima drugih autora kao i zadanim standardima kvalitete ukazuje na značajno višu učestalost konverzije epiduralne analgezije u opću anesteziju u odnosu na poželjno. Zaključak: Za približavanje svjetskim standardima kvalitete opstetričke anestezije u segmentu konverzije epiduralne analgezije u anesteziju za carski nužno je unaprijediti organizaciju rada opstetričkog anesteziološkog tima prema principu subspecijalizacije. Potrebno je uvesti jasne zajedničke protokole za rad opstetričkih anesteziologa te unaprijediti komunikaciju i koordinaciju s opstetričkim timom

Specific Features of Patient Safety Culture at the Bjelovar General Hospital and Hospitals of Similar Profile

Za poboljšanje bolesnikove sigurnosti od presudne je važnosti stvaranje kulture bolesnikove sigurnosti u zdravstvenim organizacij ama među zdravstvenim djelatnicima svih profi la. Za procjenu ili mjerenje kulture bolesnikove sigurnosti razvij en je niz alata. Najšire se primjenjuje Upitnik o kulturi bolesnikove sigurnosti u bolnici (HSOPSC), razvij en u okviru Agencij e za istraživanje i kvalitetu zdravstvene skrbi (Agency for Healthcare Research and Quality – AHRQ). Cilj rada bio je da se primjenom AHRQ upitnika procij eni stanje kulture bolesnikove sigurnosti u Općoj bolnici Bjelovar i dvij e slične bolnice u Hrvatskoj te utvrde parametri kulture bolesnikove sigurnosti ključne za izgradnju cjelovitog sustava bolesnikove sigurnosti na bolničkoj razini. Ispitivanje je obuhvatilo zdravstvene djelatnike tri opće bolnice u Hrvatskoj koji su dragovoljno i anonimno ispunili hrvatski prij evod upitnika (HSOPSC). Podaci su statistički obrađeni te je za svako pitanje prikazan omjer pozitivnih, negativnih i neutralnih stavova. Uspoređena je i statistička značajnost razlika u ocjeni stanja bolesnikove sigurnosti na odjelima te broju prij avljenih neželjenih događaju između naših ispitanika i ispitanika iz 885 američkih bolnica. Rezultati ukazuju na statistički znatno nižu učestalost prij avljivanja neželjenih događaja naših ispitanika u odnosu na američke, dok u ocjeni stanja bolesnikove sigurnosti na našim odjelima nema statistički značajne razlike. Analizom odgovora na 42 pitanja uočene su neke pozitivne osobine kulture bolesnikove sigurnosti u anketiranim bolnicama, ali i one kritične koje valja poboljšati, a to su: nekažnjavajući pristup neželjenom događaju, učestalost prijavljivanja neželjenih događaja, komunikacij ska otvorenost, timski rad, rukovođenje i popunjenost osobljem.Background. For improvement of patient safety it is of the utmost importance to create patient safety culture (PSC) in healthcare organizations and among all profi - les of health workers. A range of tools was developed for evaluation or measurement of PCS. The most widely used one is the HSOPSC developed at the Agency for Healthcare Research and Quality (AHRQ). Aim of study. To estimate the state of PCS in Bjelovar General Hospital and two similar hospitals in Croatia by applying HSOPSC, and to determine the key parameters of PSC crucial for development of an integral patient safety system at the hospital level. Methods. The research covered health workers in three general hospitals in Croatia, who voluntarily and anonymously fi lled in the Croatian version of the HSOPSC. Data analyze shows the ratio of positive, negative and neutral att itudes for each question. Statistically signifi cant diff erence in the assessment of the state of patient safety in their departments and the number of adverse events reported were compared between Croatian and US sample. Results and conclusion. The results indicate a statistically signifi cant lower incidence of adverse events reporting of our respondents in relation to the US while in assessing the state of patient safety in their departments there was no statistically signifi cant diff erence. Analysis of the responses to 42 HSOPSC questions shows some positive characteristics of PSC in the surveyed hospitals, but also those that are critical and that should be improved. These are: nonpunitive response to error, adverse events reporting, communication openness, teamwork, leadership, and staffi ng

Spinalnom anestezijom inducirana hipotenzija u opstetriciji: prevencija i terapija

Regional centro-axial anaesthesia, primarily spinal block, is the preferred method of anaesthesia for elective caesarean section because it entails fewer risks for the mother and the foetus compared to general anaesthesia. The most common side effect associated with spinal block is hypotension due to sympatholysis, occurring in up to 75% of cases. Spinal block-induced sympatholysis leads to vasodilatation and consequently causes maternal hypotension, which may compromise uterine blood flow and foetal circulation, and thus cause foetal hypoxia, bradycardia and acidosis. The selection of the most efficient treatment strategy to achieve haemodynamic stability during spinal anaesthesia for caesarean section continues to be one of the main challenges in obstetric anaesthesiology. A number of measures for the prevention and treatment of spinal block-induced hypotension are used in clinical practice, such as preloading and coloading with crystalloid and/or colloid infusion, wrapping of lower limbs with compression stockings or bandages, administering an optimal dose of local anaesthetic and achieving an optimal spinal block level, left tilt positioning, and administering inotropes and vasopressors. Instead of administering vasopressors after a drop in blood pressure has already occurred, the latest algorithms recommend a prophylactic administration of vasopressor infusion. The preferred vasoconstrictor in this case is phenylephrine, which is associated with a lower incidence of foetal acidosis, and maternal nausea and vomiting compared to other vasoconstrictors.Regionalna centroaksijalna anestezija, prvenstveno spinalni blok, danas je metoda izbora za anesteziju pri elektivnom carskom rezu jer nosi manje rizike za majku i fetus u odnosu na opću anesteziju. Najčešća komplikacija spinalnog bloka je hipotenzija koja se javlja u jedne do tri četvrtine slučajeva uslijed simpatikolize. Simpatikoliza inducirana spinalnim blokom dovodi do vazodilatacije te na taj način uzrokuje hipotenziju u majke što može kompromitirati uterini protok krvi i fetalnu cirkulaciju uzrokujući fetalnu hipoksiju, bradikardiju i acidozu. Potraga za najefikasnijom terapijskom strategijom kako bi se postigla hemodinamska stabilnost tijekom spinalne anestezije za carski rez i dalje je jedan od glavnih izazova u opstetričkoj anesteziji. U kliničkoj praksi primjenjuje se više mjera prevencije i terapije hipotenzije uzrokovane spinalnim blokom kao što je prehidracija i kohidracija infuzijom kristaloida i/ili koloida, kompresija donjih ekstremiteta elastičnim zavojima ili čarapama, optimiziranje doze lokalnog anestetika i visine spinalnog bloka, pozicioniranje s nagibom na lijevi bok te primjena inotropa i vazopresora. Umjesto primjene vazopresora nakon što nastupi pad tlaka, noviji algoritmi preporučuju profilaktičku primjenu vazopresora u infuziji pri čemu izbor pada na fenilefrin kao najčešće korišten vazokonstriktor jer se pokazalo da najmanje utječe na pojavu fetalne acidoze te mučnine i povraćanja u majke u odnosu na druge vazokonstriktore

Intrapartal uterine avulsion with posterior cervical rupture

In this case study we describe an obstetric emergency of complete intrapartum left-lateral uterine avulsion, with posterior cervical rupture in a 31-year-old secundipara, following vacuum extraction. To the best of our knowledge, a similar case has not been previously reported in the literature. A live macrosomic male neonate was delivered by two tractions, with lateral episiotomy, and with shoulder dystocia that was relieved by McRoberts’ and Resnik’s maneuvers (Apgar score 7.8, birth weight/length 4640/57). In our patient, the risk factors for avulsion and concomitant posterior cervical rupture included prolonged second stage of labor, delivering a macrosomic neonate in a secundipara with deflexion (parietal) in a cephalic presentation along the distended and thinned posterior uterine wall. Urgent total hysterectomy was performed in dramatical circumstances due to complete unilateral avulsion and cervical rupture, with continuous aortal compression, volume replacement and intact coagulation, which certainly contributed to the good final maternal outcome