The author describes a case of vaginal delivery in which the mother dies. Because of a retained placenta parts in cavum uteri, the physician peroformed revisio cavi uteri instrumentalis, in which wall of the uterus is perforated, about 3 cm in length. A justice commission of seven persons associate the bleeding out of the uterus and the death of the mother with the perforation of the uterus. We consider that the death of the mother is due to amniotic embolism and not due to the perforation of the uterus. We cite contemporary scientific data.

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