I would like to narrate the following case. A woman pregnant for the second time presented at 24 weeks of pregnancy with shock. She had no live children. She experienced severe abdominal pain and bleeding from the vagina 1 h before the presentation. On examination, she was in haemorrhagic shock with obvious features of haemoperitoneum and superficial foetal parts and absent foetal heart sounds. At laparotomy, there was more than a litre of haemoperitoneum. It was agonizing to find a Z-shaped ragged rupture of the anterior wall of the upper segment (Fig. 4.1a). The dead foetus was lying in the peritoneal cavity. The edges were briskly bleeding. I had to resort to hysterectomy. The procedure and recovery were uneventful. The past obstetric history available in her documents was a wake-up call. The woman had been admitted in her first pregnancy to our hospital with a diagnosis of abruption and foetal demise due to preeclampsia at term. Labour had been induced, and she delivered. There was a massive atonic postpartum haemorrhage. Systematic devascularization and internal iliac artery ligation failed to arrest bleeding. In a desperate attempt to save the uterus, as she was nulliparous, the consultant had given box sutures in the anterior wall of the uterus (Fig. 4.1b) to compress it tightly. The sutures succeeded in controlling the bleeding, and the uterus was conserved. She had an uneventful recovery after receiving multiple blood and component transfusions.

It was the bites of the box suture in the upper segment given at the previous laparotomy that behaved like an upper segment scar and ruptured in the second trimester of the subsequent pregnancy. It is therefore very important to understand that no compression sutures should ever involve taking bites through the upper segment of the uterus.

It is mysterious how and when the upper segment becomes weak.

I encountered this case about 14 years back. A woman presented in her second pregnancy at 36 weeks of gestation with breech presentation and premature rupture of membranes. The index pregnancy was spontaneous conception. In the first pregnancy 2 years back, she had a spontaneous vaginal delivery attended at home by an untrained attendant. There was a history of difficult placental delivery. She had presented to our hospital 3 days after delivery with features of grade IV puerperal sepsis with frank peritonitis. A laparotomy then revealed 1 l of pus in the peritoneal cavity with a puerperal uterus. Peritoneal lavage and drainage were carried out. She had made an uneventful recovery and had been discharged after 10 days of hospital stay. Given premature rupture of membranes with flexed breech presentation, caesarean section was decided and performed. To our immense surprise, there was a ragged old rent in the fundus of the uterus through which the membranes were bulging out. A lower segment incision delivered a 2.2 kg baby. The edge of the fundal rent was freshened for repair, but the wide ragged edges with bleeding compelled me to perform a hysterectomy (Fig. 4.2). I could only thank the Almighty for giving her breech presentation without labour and thus making our decision for caesarean clear cut. If only she had gone into spontaneous or induced labour, there would have been a calamity. Some women are indeed lucky.

Manual removal of the placenta has been associated with problems. A forceful removal of an adherent placental lobe could result in weakening resulting in bleeding infection or even rupture.