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A year after a fundal myomectomy performed as day surgery, a 39-year-old primigravida presented with complete uterine rupture at 36 weeks of gestation. A dead female baby was found lying below the diaphragm and a lot of blood was found inside the abdominal cavity. The uterus was repaired. A year later, another spontaneous pregnancy ensued. A healthy female baby weighing 2100g was delivered by elective cesarean section at 34 weeks. Careful hospital management and scheduled elective cesarean delivery could be a way of achieving a favorable outcome.

Thirty-six cases of obstetrical rupture of the uterus over a thirty-two-year period at the Woman's Hospital are presented. As over half of these ruptures occurred in patients who had previously been delivered by cesarean section, it therefore seems wiser to pursue a policy of “once a cesarean, always a cesarean.” Granted that some patients with adequate pelves may safely be delivered vaginally following previous cesarean section, this fact, nevertheless, should not give one a sense of false security, as it is no guarantee that the uterus of such a patient will not rupture during a subsequent labor. Other predisposing factors such as previous myomectomies and complicated vaginal deliveries are also discussed and certain recommendations made.

A case report is presented of a patient operated upon for partial separation of the normally implanted placenta. Massive hemorrhage (3,000 c.c.) occurred within a matter of three minutes after opening the uterus. The placenta had to be removed manually, and it would appear that the uterus was unknowingly ruptured during this procedure. The initial measured blood loss was in excess of one-half the estimated blood volume, and simultaneous replacement of blood and plasma by multiple transfusions during the day of operation represented eight-ninths of the estimated blood volume. The calculated blood volume of the patient at the time of operation was 6,200 cubic centimeters. The total blood loss was estimated at 5,700 cubic centimeters and the replacement of blood and plasma amounted to 7,750 cubic centimeters.

Two cases are here reported, which were strikingly similar except that, in the second, the bladder itself did not rupture but acted as a tampon to the tear in the uterine lower segment, while, in the first case, rupture of the lower segment into the bladder took place. The second patient had been unwisely allowed to remain in hard labor for several hours before the consultant was called, and rupture had taken place when the patient was first seen by the author.

Summary 1. A case is presented illustrating the occurrence of uterine rupture of a severe degree without the dramatic symptoms usually associated with this condition. 2. Attention is drawn to the importance of strict observation ot patientsin the “fourth stage of labor” as regards nonresponding blood prcssnre ill the shock levels, with or without excessive vaginal bleeding. 3. The severe degree of the uterine laceration with the minimal symptoms leads one to postulate that many cases of less severe rupture must go unrecognized and be precursors of later, more severe, rupture.