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Sir,

I read with great interest the article by Turner et al.1 reporting their experience in the management and outcomes of vaginal birth after prior caesarean (VBAC) over a 10-year period. They confirmed that management of labour and delivery for women with a prior caesarean section, including a high rate of attempted trial of labour, a low rate of labour induction and prostaglandin use, accompanied by partograms and fetal scalp blood sampling, could be associated with a high rate of successful VBAC and a very low rate of uterine rupture with its potential for neonatal morbidity. Moreover, they found a higher rate of uterine rupture with prostaglandins (1.4%) and labour induction (1.1%) but no difference with the wise administration of oxytocin for labour augmentation (0.2%). The numbers of women involved were obviously too small to give statistically significant differences, but these ratios, in a population with an overall low rate of uterine rupture (0.2%), remain in agreement with prior literature. This work will definitely help in the difficult task of counselling women on the choice between trial of labour versus elective repeat caesarean.

Besides labour induction in women with an unfavourable cervix, with or without prostaglandins, another factor seems to have played an important role in the higher rates of uterine rupture in North America over the past two decades. In a cohort study published in 2002, prior, single-layer, locked closure of the uterus was found to be associated with a four- to five-fold increase in the rate of uterine rupture.2 The relationship between this type of closure and uterine rupture was confirmed in a very large case–control trial (complete data under publication process).3 While the single-layer locked uterine suture was integrated in common practice in North America from the late 1980s, I believe that it never became very popular in European countries, explaining, in part, the overall lower rate of uterine rupture in the European continent. However, the hypothesis has never been confirmed by randomised controlled trials or other comparative studies. Therefore I am wondering, first, if the common surgical practice in the centre of Turner et al. was to close the uterus incision in a way different from single-layer, locked closure and, second, if they evaluated prior uterine closure of the nine women who experienced uterine rupture in their cohort.

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