This was a case of a 23-year old G4 P3 A3 woman at a gestational age of 39 weeks in April, 2017 who was referred to the labour ward of the University of Calabar Teaching Hospital (UCTH), Calabar, Southern Nigeria, with a history of inability to deliver her baby after 5 days in labour prior to presentation. The patient had been managed in two different traditional birth attendant (TBA) homes. The second TBA recognized that the cause of prolonged labour was abnormal lie of the fetus and attempted to correct the lie by intrauterine manipulation through the vagina. This resulted in uterine rupture and subsequent evisceration of the intra-abdominal viscus through the vagina. The loop of the small intestine was initially mistaken for umbilical cord by the TBA who pulled several lengths of it through the vagina (Figure 1). Following the failed attempt to deliver the baby and the woman's deteriorating clinical state, the patient was subsequently rushed to UCTH.
At UCTH, the patient was resuscitated. Parenteral broad spectrum antibiotics were administered. The extruded loops of bowel were wrapped in sterile guaze soaked with warm normal saline. A general surgeon was invited to take part in the management of the patient. The patient was immediately prepared and taken to theatre for emergency laparotomy.
A midline incision was made to access the peritoneal cavity. Intra-operatively, a macerated female fetus was found in the uterine cavity. There was a left postero-lateral uterine wall tear extending from the mid portion to the posterior vaginal fornix. The loops of bowel extruded through this opening. The dead fetus was extracted. About 1,200 ml of blood in the peritoneal cavity was suctioned. Total abdominal hysterectomy was performed.
The whole intestines were thoroughly examined (Figures 2 and 3); about half the length of the intestine was devitalized and therefore, resected and an end-to-end anastomosis was done. The peritoneal cavity was lavaged with warm normal saline before abdominal wall closure. Nasogastric tube was then inserted.
Post-operatively, the patient was given parenteral nutrition for 5 days. Antibiotics, analgesics and other supportive treatments were continued according to our protocols. The patient opened bowel on the eighth post-operative day. The patient was commenced on graded oral meals which the patient tolerated. Subsequent post-operative days were uneventful. The patient was later discharged home.