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Vaginal delivery after caesarean section triples risk of uterine rupture

BMJ 2001; 323 doi: (Published 14 July 2001) Cite this as: BMJ 2001;323:68

Single-Layer Suturing in Caesarean Section Should be Abandoned Until Proven Safe

To the Editor: Josefson 1 reports that Lydon-Rochelle et al. found a
tripling of uterine rupture risk with trial of labor compared to repeat
caesarean section. Similarly, about a doubling of risk for trial of
labour was reported for California in 1995 and in a recent evaluation in
Switzerland.1 These analyses, however, appear to be at odds with a 1991
meta-analysis of studies conducted in the United States in the 1980s
comparing trial of labour with repeat caesarean section.2 The meta-
analysis did not find increased uterine rupture risk associated with trial
of labor after caesarean section in the 11 studies (6,328 births)
examining the issue.

We propose that the risk differential in Washington, California and
Switzerland between repeat caesarean and trial of labor may be the result
of a change in caesarean clinical practice in the late 1980s, when single-
layer closure of the uterine incision became popular.3 A recent
evaluation in Montreal covering 1990-2000 found a five-fold increase in
uterine rupture associated with single-layer versus the traditional double
-layer method.4 Among the 398 women with single-layer closure, the
rupture rate was 3.3%, whereas among the 1,251 women with double-layer
closure, the risk was 0.6%. Single-layer suturing could have a
particularly large impact on the uterine rupture rate among those women
induced or augmented during labour.

Introduction of the single-layer method does not seem to have been
based on published evidence of safety in general or evidence of not
increasing uterine rupture in subsequent pregnancies in particular. A
Cochrane Review of single- versus double-layer closure reported no studies
examining the relative safety in relation to uterine rupture in subsequent
births.5 It is a reasonable possibility that the increased trial of labor
risk observed by Lydon-Rochelle may be the result of single-layer suturing
in a woman's prior caesarean, suggesting that single-layer suturing should
be abandoned until its safety related to uterine rupture in subsequent
trials of labor can be established.

Kenneth C. Johnson, Ph.D.,
Consultant Epidemiologist

Statistics and Research Committee,
Midwives Alliance of North America

36 Glen Ave, Ottawa, Ontario K1S 2Z7, CANADA

Ina May Gaskin,
Midwives Alliance of North America,

41, The Farm
Summertown, TN 38483, USA

1. Josefson D. Vaginal delivery after caesarean section triples risk
of uterine rupture. BMJ 2001;323:68; reporting on: Lydon-Rochelle, M, et
al. Risk of uterine rupture during labor among women with a prior cesarean
delivery. N Engl J Med 2001:345(1):3-8.

2. Rosen MG et al. Vaginal birth after cesarean: a meta-analysis of
morbidity and mortality. Obstet Gynecol 1991:77(3):465-470.

3. Bivins HA et al. C/S closure techniques: which work best? OBG
Management, April 2000.

4. Bujold E, Bujold C, Gauthier RJ. Uterine rupture during a trial of
labor after a one- versus two-layer closure of a low transverse cesarean.
Abstracts of the 2001 21st Annual Meeting of the Society for Maternal-
Fetal Medicine. Amer J Obstet Gynecol (supplement) 184(1):S18, 2000.

5. Enkin MW, Wilkinson C. Single versus two layer suturing for
closing the uterine incision at Caesarean section (Cochrane Review) The
Cochrane Library, Issue 2, 2001. Update Software Ltd.

Competing interests: No competing interests

28 September 2001
Kenneth C Johnson
Consultant Epidemiologist; President
Ina May Gaskin
Midwives Alliance of North America