Rupture of a caesarean scar during a trial of vaginal birth: a dramatic consequence as old as the modern caesarean section.

Abstract

Among other pioneering surgical procedures, John Hunter (1728–1793), the father of modern surgery, is credited to have performed the first caesarean section deliveries using an evidence-based anatomical approach (Moore W, The Knife Man, Bantam Press, 2005). Even if his procedures were technically successful – and Hunter managed to deliver a few live and surviving babies – the mother inevitably died, mainly because of the lack of suitable suturing material and wound infection. Thus, until the 19th century, caesarean section remained a surgical procedure of last resort performed almost exclusively to save the baby's life. It is only when surgeons started to suture the uterus after delivery that the maternal death rate started to fall. Further technical advances in surgical techniques during the early 20th century reduced the complication rates of caesarean section substantially. As a result, mothers not only survived the surgical procedure but were also able to have one or more subsequent pregnancies. With the rising numbers of caesarean sections came new complications in subsequent pregnancies and, in particular, rupture of the previous uterine scar became more commonly reported in the medical literature. In 1921, in a special issue on caesarean section published by this journal, Eardley Holland (1880–1967), consultant at the London Hospital, reported on five cases of scar rupture leading to maternal death during pregnancy or labour (Holland E, J Obstet Gynecol Br Emp 1921;28:488–522). Holland recalled having performed the primary caesarean section of one of these patients 5 years earlier, and stated that: ‘The occurrence of these treacherous accidents made a very great impression on the minds of myself and my colleagues’. His inquiry indicated that there was little information about the causes and frequency of scar rupture after caesarean section, and that ‘certain surgeons were so afraid of ruptured scar that they sterilize their patients at the first operation’. The classical caesarean section is associated with the greatest damage to the uterine wall, and not surprisingly with the highest risk of ruptured scar in subsequent pregnancies, before and during labour. Low-segment caesarean sections are rarely associated with spontaneous scar rupture during pregnancy, but are observed in one in 250 spontaneous labours, and the risk is higher when labour is induced with prostaglandins (Landon et al., NEJM 2004;351:2581–9); however, the reason why some women rupture their scar and others do not remains unclear. Variations in surgical techniques or different suture material used do not seem to explain scar rupture in subsequent pregnancies (Roberge et al., Int J Gynaecol Obstet 2011;115:5–10). The use of continuous fetal heart monitoring during labour and access to fluid infusion and blood transfusion has reduced fetal and maternal morbidity and mortality in deliveries complicated by ruptured uterine scar. The data analysis of a representative sample of the French obstetric population indicates that the incidence of elective repeat caesarean section is well above that expected from the national guidelines for women eligible for a trial of scar (Bartolo et al., BJOG, in this issue). They suggest that non-medical reasons are involved in the decision. Perhaps collective memory of the dramatic consequences of a ruptured scar still influences doctor and patient choice. None declared. Completed disclosure of interests form available to view online as supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.