combined uterine and urinary bladder rupture following prolonged obstructed labor is indeed a momentous uro - obstetric emergency . the urinary bladder involvement is distinctly rare in the absence of factors that predispose the bladder to be adherent to the lower uterine segment and is quite unusual in a primigravida . to report a rare case of uterine rupture involving urinary bladder secondary to a prolonged obstructed labor in a primigravida from a low resource setting . a 17-year - old married unbooked primigravida who presented with a 3-day history of spontaneous onset of labor at term that was initially managed at home and later in a primary health care center where she had fundal pressure and oxytocin augmentation , respectively . the postoperative period was uneventful and she was followed - up at the gynecology and family planning clinics . there is a need for community reawakening on the inherent risks of teenage pregnancy , bad obstetric practices , and unsupervised pregnancy , labor , and delivery , particularly in the rural settings as in the index patient . a high index of suspicion and prompt appropriate intervention will reduce the sequel of morbidity and occasional mortality from this predicament . uterine rupture involving the urinary bladder in labor and delivery is a momentous uro - obstetric emergency that results in stillbirth , maternal morbidity , and occasional maternal fatality.1 uterine rupture is unusual in the primigravida . in the few isolated recorded cases of uterine rupture from prolonged obstructed labor in the primigravida , bladder rupture is distinctly rare.2,3 we obtained a written informed consent from the patient to report this unusual intricacy of labor and delivery . the patient was a 17-year - old unbooked primigravida who was uncertain of her date but was said to be 9 months pregnant at the time of her presentation to the mdecins sans frontires france ( msf - f ) emergency obstetrics , neonatal , and vesico - vaginal fistula ( vvf ) care center in jahun , jigawa state , northern nigeria . she presented as a referral from a primary health care center ( phcc ) approximately 100 km from jahun town . we obtained approval from the jigawa state ministry of health ethics committee to report these unusual complications of labor in a primigravida . she was apparently well when she went into spontaneous labor 3 days prior to the presentation . the labor was under the supervision of a traditional birth attendant at home for 2 days . she had oral traditional medicaments , fundal pressure , and later a  gishiri cut the labor pain became relentless with the involvement of the whole abdomen that necessitated her presentation to a close - by phcc . she had oxytocin augmentation with 10 iu given as intramuscular injection and 20 iu via an intravenous fluid at the phcc ; nonetheless , her condition deteriorated with associated high - grade fever , inability to void urine , vomiting , vaginal bleeding , chest pain , and difficulty in breathing before her referral to msf - f a day after her presentation to the phcc . she had no known comorbidity , no antecedent abdominopelvic surgery , no abdominal trauma , no history signifying previous pelvic inflammatory disease , and no history suggestive of urinary tract pathology . she was married to a 22-year - old petty trader , had no formal education , nor was she gainfully employed . at presentation , she was acutely ill - looking , febrile ( axillary temperature 39c ) , dehydrated , pale but anicteric . her pulse rate was 130 per minute , regular with moderate volume ; her blood pressure was 100/70 mmhg , and the heart sounds were i and ii only . the abdomen was grossly distended with bandl s ring and symphysio - fundal height of 41 cm . fetal parts were freely felt ; singleton fetus , longitudinal lie , and cephalic presentation with a descent of 3/5th . a diagnosis of a ruptured uterus with urinary bladder involvement secondary to prolonged obstructed labor and sepsis in a primigravida was made . she had normal electrolyte but elevated urea and creatinine levels that normalized following her resuscitation . the hiv and hepatitis b surface antigen tests were negative and the random blood glucose with liver function test were normal . the findings at the surgery included thick foul smelling liquor and a fresh stillborn male baby weighing 3.85 kg . there was a ragged lower uterine segment rupture that extended down to the uterine cervix with posterior urinary bladder rupture measuring 8 cm and the urethral catheter balloon visible outside the bladder ( figure 1 ) . she had uterine and urinary bladder repair in double layers ( figures 2 and 3 ) . the estimated blood loss was 450 ml and she had two units of whole blood transfused . she had sitz bath for the genital mutilation and was discharged home on the 12th day postoperation on hematinics after the removal of the urinary catheter . at her consecutive follow - up , the wound had healed completely ; she was continent of urine , had no lower urinary tract symptoms , and was thereupon commenced on family planning . in spite of the notable global gains in health care delivery , maternal and child health has prevailed as a great health challenge in the developing countries.4 many national and international bodies , including governmental , intergovernmental , and nongovernmental bodies,5 have devoted resources aimed at curbing the high maternal morbidity and mortality . msf - f has been in nigeria since 1996 . in collaboration with jigawa state ministry of health and indigenous specialist health caregivers , msf - f offers free health care services in jahun general hospital at the maternity / vvf section since 2008.6 their main objectives include bettering the access to obstetric and neonatal care , hence , lowering the maternal and neonatal mortality rates in addition to improving the care for patients with obstetric fistula . principally , patients from the northwest region of nigeria and a part of niger republic receive care from the center . the analysis of the services offered by the center in 2013 showed that greater than 70% of the admissions were from complications of pregnancy , labor , and delivery.7 the index patient , a primigravida , presented as a referral from a phcc approximately 100 km away which might have contributed to the delay in her presentation.8 the patient s prolonged obstructed labor of 3 days was further complicated by the uterine rupture involving the urinary bladder . our literature search revealed that the nigerian former minister of health ( 1961 to 1966 ) , ma majekodounmi , was the first known nigerian author who reported a case of the unscarred uterine rupture with urinary bladder involvement he managed in 1954 ; but that patient was a multigravida.9 this is the first primigravida with combine uterine and urinary bladder rupture who presented to the msf - f center in jahun and among the very few reported . our quest of pubmed divulged a single case managed in a tertiary maternity hospital , kathmandu , nepal , in their 20-year review of 251 patients with a ruptured uterus.2 the urinary bladder involvement in uterine rupture is distinctly rare in the absence of adhesions of the urinary bladder to the lower uterine segment ; hence , rare in the unscarred uterus9 and distinctly unusual in a primigravida . supplementary to her delay in presentation , the index case displayed much of the harmful time - honored practices still a tradition in some of the rural settings in nigeria . the harmful traditions included concoctions ingested during labor and delivery under the supervision of the traditional birth attendants1012 ; this contributed to the index patient presenting clinical state . pan et al reported uterine rupture in an unscarred uterus after application of fundal pressure;13 the index patient had fundal pressure while at home . urine retention during labor is not unusual ; trivial trauma or significant pressure could lead to rupture of the distended bladder in an unsupervised labor and delivery in addition to it hindering the progression of labor , as may probably be the case in our patient . abdominal massage - related urinary bladder rupture and spontaneous rupture though rare have been reported in a distended bladder.14,15 hence , the fundal pressure in a distended bladder could have contributed to the urinary bladder involvement as these traditional birth attendants do not have the expertise of draining the distended urinary bladder . the patient had oxytocin at the primary health care facility ; these centers often have little or no experience of safe augmentation using oxytocin . oxytocin - associated rupture of an unscarred uterus in a primigravida was recognized in the literature.16 our patient had a total of 30 iu of oxytocin both by intramuscular injection ( an erroneous dose and route of administration ) and intravenous infusion at the phcc . the teenage pregnancy that was unbooked , the formal education she lacked , and her poor economic status are established factors that contributed to poor health - seeking behavior and a bad obstetric history along with an unfavorable outcome in our patient . the clinical features in the patient were classical of uterine rupture with urinary bladder involvement.1,2,9 she was therefore appropriately managed as a uro - obstetric emergency by prompt resuscitation , evaluation , and laparotomy.1 at the laparotomy , the diagnosis was confirmed ; cystoscopy was not done because the center does not have the facility and time was a big issue for her survival and the outcome . the patient , fortunately , had uneventful recovery before her discharge and at consecutive follow - ups . she was additionally counseled that her ensuing pregnancy and labor must be medically supervised and delivery should only be in a center with facility and expertise to handle high - risk deliveries . uterine rupture is not common among primigravidas and urinary bladder involvement is particularly unusual ; hence , a high index of suspicion helps in the management . there is a need for continuous community reawakening on the inherent imperils of teenage pregnancy , harmful traditional obstetric practices , and those of unsupervised pregnancy , labor and delivery .
backgroundcombined uterine and urinary bladder rupture following prolonged obstructed labor is indeed a momentous uro - obstetric emergency . 
 the urinary bladder involvement is distinctly rare in the absence of factors that predispose the bladder to be adherent to the lower uterine segment and is quite unusual in a primigravida.objectiveto report a rare case of uterine rupture involving urinary bladder secondary to a prolonged obstructed labor in a primigravida from a low resource setting.casea 17-year - old married unbooked primigravida who presented with a 3-day history of spontaneous onset of labor at term that was initially managed at home and later in a primary health care center where she had fundal pressure and oxytocin augmentation , respectively . 
 the labor was complicated by combined uterine and urinary bladder rupture with sepsis . 
 she was resuscitated and had exploratory laparotomy with uterine and urinary bladder repair . 
 the postoperative period was uneventful and she was followed - up at the gynecology and family planning clinics.conclusionthere is a need for community reawakening on the inherent risks of teenage pregnancy , bad obstetric practices , and unsupervised pregnancy , labor , and delivery , particularly in the rural settings as in the index patient . 
 a high index of suspicion and prompt appropriate intervention will reduce the sequel of morbidity and occasional mortality from this predicament .