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Uterine rupture and labour after a previous low transverse caesarean section

Author’s Reply

Sir,

I welcome Prof Bujold’s comments.1 While the number of women with a previous caesarean section who had labour induced in our study was small,2 the increased rate of uterine rupture compared with women who went into spontaneous labour is consistent with previous studies in our own hospital3,4 and larger studies elsewhere.5

In our recent study, women with a previous low transverse incision who went into spontaneous labour and who did not receive oxytocin augmentation had a rupture rate of only 0.1%. The cautious use of oxytocin augmentation2 in spontaneous labour was associated with a rupture rate of 0.2%. Professor Bujold highlights the importance of this information in counselling women antenatally on the risks of vaginal birth after one previous caesarean section. Based on our experiences, quoting a risk of 1% uterine rupture associated with a trial of labour seriously overstates the risk for many women who are considering vaginal birth after caesarean (VBAC).6 Misleading information about the risks of attempting VBAC may contribute to the continuing increase in the caesarean section rate worldwide.

Our standard practice for the closure of the lower uterine segment is double-layer suturing. It is not possible to determine from the clinical records whether obstetricians lock the first layer or not. As is often the case in obstetrics, it is difficult to tease out the contribution of individual variables, such as wound closure, in determining the risk of subsequent uterine rupture. The implementation of stricter clinical guidelines, however, including the introduction of a colour-coded partogram, has been associated with a decrease in the rate of uterine rupture in women with a previous caesarean section from 0.42% in the decade 1982–912 to 0.27% in the decade 1993–2002.2

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