We thank our colleagues Reynolds and O’Sullivan1 for their useful comment on our paper.1 They address two issues. Regarding the first, the caesarean rate in the Netherlands is among the lowest of the Western world. Although they state that the overall caesarean rate in Africa is estimated to be around 1%, there is no such thing as ‘Africa’. The statement may be true for some of the rural areas, but is certainly untrue of the Caesarean rates in urban areas. Unfortunately, Caesarean rates rise sharply, and not always for good reasons (for instance instrumental vaginal delivery is rarely practiced nowadays). The statement that ‘worldwide the major cause of uterine rupture is the absence of Caesarean delivery’ is also astonishing. The statement should be: in high-resource settings most ruptures are scar ruptures, and in low-resource settings most ruptured uteri are unscarred, and result from obstructed labour, which is non-existent in resource-rich settings.
The second issue raised by the authors concerns the continuing debate on the causal relationship between epidural analgesia and uterine rupture. We are not an exponent of the ‘vocal anti-epidural lobby’ and, in fact, the use of epidural analgesia is increasing in the Netherlands. The new Dutch guidelines on analgesia during labour state that epidural analgesia should be available at any time, upon request. Although we absolutely agree with Reynolds and O’Sullivan that the relative risk of 10.7 for epidural analgesia does not infer any causal relationship, and that there are several obvious confounding factors, we would not be surprised if there was a direct relationship, as timely diagnosis of uterine rupture could be hampered by epidural analgesia. When only compared with the high-risk population under the care of an obstetrician, the relative risk of uterine rupture in women with epidural analgesia remains about 6 (40% versus 10% epidural analgesia).
Epidural analgesia is a valuable tool in achieving optimal vaginal birth after caesarean section (VBAC) rates. Its judicious use, including careful consideration of the cause in case of insufficient analgesia, as also suggested by Reynolds and O’Sullivan, could reduce the uterine rupture rate in women with epidural analgesia. Our cohort study indicates the need for further research into the role of epidural analgesia in uterine rupture. It does not provide any evidence in relation to this issue.