Document Type

Case Report



To present the case report of a woman who died during her third delivery due to the mismanagement of her labour. The woman had had one previous caesarean section and tried for vaginal delivery with injudicious use of oxytocin, leading to a rupturing of the uterus and death.

Methods & Result

During a maternal death audit it was found that a 28-years old woman (para 2) Meena (name changed to maintain anonymity) had died. Meena had one previous normal vaginal delivery and a second delivered by caesarean section. In her third pregnancy she did not take have any antenatal check-ups with a midwife or a doctor although she visited community health care providers up to 38 weeks of gestation. On the day her labour started she developed lower abdominal pain in the morning and was in established labour by the evening. The community health worker attended but refused to deliver at home and advised to take her in the hospital. However, her parent called a village doctor, who tried to conduct the delivery and augment labour with intravenous oxytocics. Meena died due to haemorrhage and shock following ruptured of the uterus. During the audit it was found that Meena’s parents, the community health worker and the village doctor lacked awareness, whilst the health professionals lacked knowledge to manage such a pregnancy and were unwilling to take responsible for the disastrous outcome.


The key to successful management of such cases is proper antenatal check-ups, counseling and planned delivery at a hospital which can offer emergency obstetric care. Legislation and regulation should be implemented to prevent such malpractice by village doctors with poor knowledge. There is a need for protocols to manage such high-risk pregnancies by the local health care providers as well as training to help recognise problems early in community settings.