Any uterine incision that extends to interrupt the lateral
neurovascular bundle threatens the innervation of the anterior uterine
wall above this level. Recurrent, preterm and late Caesarean section may
be frequent causes. Focal, hyperechoic changes of the anterior uterine
wall may reflect disruption of the normal vascular patterns. Severe
adenomyosis is strongly associated with uterine denervation (1) and may
require hysterectomy in later life (another denervatory event).
Disruption of myofascial pelvic supports during labour inevitably
damages branches of the inferior hypogastric plexi (denervation) and may
create the conditions for reinnervation. Collateral sprouting and
chaotic, small-diameter nerve fibres have been identified in uterus,
vagina, vulva, uterosacral ligaments and bladder (2). Chronic pelvic
pain, menstrual dysfunction, dysmenorrhoea, dyspareunia, irritative
bladder and bowel symptoms are the contemporary labels for these
consequences.
Both abdominal and vaginal delivery carry clear though unquantified
threats to the pelvic innervation. The epidemic of teenage pregnancy is
bringing serious gynaecological problems to the clinic in women under the
age of twenty five. What happens to a woman during her first delivery
(abdominal or vaginal) may place her on a trajectory of pain and misery
for the rest of her life. If Brazilian women were aware of these concerns
would they submit themselves to Caesarean section in their present numbers
(3) ? Obstetric fashion needs to be replaced by robust facts about the
remote consequences of different patterns of labour and delivery.
Comprehensive and appropriate datasets are available; some better
questions may have to be asked ?
(1) Differences in uterine innervation at hysterectomy.
MJ Quinn, N Kirk, MC Slack, MD Harris.
Presented at Society of Gynecological Surgeons, Dallas, March 2002.
(2) Obstetric denervation – Gynecologic reinnervation
MJ Quinn, N Kirk, MC Slack, MD Harris.
Am J Obstet Gynecol 2002;, Jan; 186(1):168.
(3) Consumer demand for caesarean sections in Brazil: population
based birth cohort study linking ethnographic and epidemiological methods.
Behague DP, Victora CG, Barros FC,
BMJ 2002; 324:942-945.
Rapid Response:
Remote consequences of Caesarean section
Any uterine incision that extends to interrupt the lateral
neurovascular bundle threatens the innervation of the anterior uterine
wall above this level. Recurrent, preterm and late Caesarean section may
be frequent causes. Focal, hyperechoic changes of the anterior uterine
wall may reflect disruption of the normal vascular patterns. Severe
adenomyosis is strongly associated with uterine denervation (1) and may
require hysterectomy in later life (another denervatory event).
Disruption of myofascial pelvic supports during labour inevitably
damages branches of the inferior hypogastric plexi (denervation) and may
create the conditions for reinnervation. Collateral sprouting and
chaotic, small-diameter nerve fibres have been identified in uterus,
vagina, vulva, uterosacral ligaments and bladder (2). Chronic pelvic
pain, menstrual dysfunction, dysmenorrhoea, dyspareunia, irritative
bladder and bowel symptoms are the contemporary labels for these
consequences.
Both abdominal and vaginal delivery carry clear though unquantified
threats to the pelvic innervation. The epidemic of teenage pregnancy is
bringing serious gynaecological problems to the clinic in women under the
age of twenty five. What happens to a woman during her first delivery
(abdominal or vaginal) may place her on a trajectory of pain and misery
for the rest of her life. If Brazilian women were aware of these concerns
would they submit themselves to Caesarean section in their present numbers
(3) ? Obstetric fashion needs to be replaced by robust facts about the
remote consequences of different patterns of labour and delivery.
Comprehensive and appropriate datasets are available; some better
questions may have to be asked ?
MJ Quinn, MD, MRCOG, Hinchingbrooke Hospital, Huntingdon, PE29 6NT.
martin.quinn@hbhc-tr.anglox.nhs.uk
(1) Differences in uterine innervation at hysterectomy.
MJ Quinn, N Kirk, MC Slack, MD Harris.
Presented at Society of Gynecological Surgeons, Dallas, March 2002.
(2) Obstetric denervation – Gynecologic reinnervation
MJ Quinn, N Kirk, MC Slack, MD Harris.
Am J Obstet Gynecol 2002;, Jan; 186(1):168.
(3) Consumer demand for caesarean sections in Brazil: population
based birth cohort study linking ethnographic and epidemiological methods.
Behague DP, Victora CG, Barros FC,
BMJ 2002; 324:942-945.
Competing interests: No competing interests