Correspondence
Case 9-1998: Uterine Rupture
N Engl J Med 1998; 339:268-269July 23, 1998
- Article
To the Editor:
The cardiovascular collapse and death of a healthy 38-year-old woman considered an “excellent candidate” for vaginal delivery after cesarean section (March 19 issue)1 should raise some doubt in the minds of those who fervently promote this practice. If the rate of uterine tear is 1 percent and 12 to 15 percent of all deliveries in the United States are by primary cesarean section, we can calculate the occurrence of uterine tear to be 4000 to 5000 per year.
This complication is often associated with fetal damage and, not infrequently, with fetal or neonatal death. Maternal mortality, although not as frequent, still occurs as described in the Case Record. In the absence of a reliable method that can predict the strength of a uterine scar, the incidence of this complication is not reducible. Reassurances that a uterine tear can be safely managed by an emergency cesarean section are equally unfounded.
Despite this background, vaginal delivery after cesarean section is strongly promoted as safe. Pressure is applied to physicians by third-party payers (financial pressure) and heads of obstetrics and gynecology departments (statistical pressure). The percentage of cesarean sections an obstetrician performs becomes a measure of the doctor's ability, regardless of other complications. Although the effort to reduce the rate of cesarean sections in the United States is commendable, clinicians must be careful to avoid giving in to pressure from an organization whose bottom line is tied to financial or statistical measures.
Fairness demands that the final decision about whether a vaginal delivery after cesarean section should be attempted be made by the woman herself, with all the facts at hand. It has been my experience in 30 years of obstetrics practice that many “excellent candidates” shy away from this method of delivery once they learn about the possibility of uterine tears.
1 ReferencesRobert R. Weiss, M.D.
Bethpage Ob-Gyn, Bethpage, NY 117141
Case Records of the Massachusetts General Hospital (Case 9-1998)
Full Text | Web of Science | Medline
To the Editor:
What is “safe”? Uterine rupture is frequently catastrophic. If it happens in 1 percent of all attempted vaginal deliveries after cesarean section, physicians should be prepared to perform an immediate cesarean section at the slightest sign of a problem. But they are not. In the case under discussion, the fetal heart rate dropped to the mid-70s three times, and each deceleration lasted two to three minutes. How did these physicians know that this was not the first (or second or third) sign of uterine rupture?
In my opinion, the obstetrical community has compromised the standard of care. We have bowed to the financial pressure of increased costs associated with repeated cesarean sections and to the very natural and understandable desire of women to experience vaginal delivery. Malpractice lawsuits directed at disasters resulting from vaginal deliveries after cesarean section are escalating, but the moral issue is more important: Should we perform 250 or 500 cesarean sections to save one baby's life, one baby's brain, or one mother's uterus?
Thomas M. Murray, M.D.
Fishkill, NY 12524To the Editor:
The definitive diagnosis of amniotic fluid embolism requires morphologic identification of fetal products in maternal-lung tissue (epithelial squames from fetal skin, lanugo hair, fat from vernix caseosa, and bile from contamination with meconium). In the Case Record, the finding of fat globules in pulmonary capillaries should not be taken as confirmation of the presence of amniotic fluid embolism. The patient was undergoing vigorous cardiopulmonary resuscitation. Microglobules of fat can often be found in the small pulmonary vessels after vigorous cardiopulmonary resuscitation.1 They are released by injury to bone marrow, and they gain access to the circulation through rupture of the vascular sinusoids.
1 ReferencesFrancisco Vega Vázquez, M.D., Ph.D.
Complejo Hospitalario Cristal-Piñor de Orense, 32003 Orense, Spain1
Walley VM ,Guindi MM ,Stinson WA . Regurgitation of fat and marrow emboli into coronary veins during resuscitation. Arch Pathol Lab Med 1991;115:65-67
Web of Science | Medline
Author/Editor Response
The authors reply:
To the Editor: Drs. Weiss and Murray express anger, frustration, and revulsion because they perceive the current enthusiasm for vaginal deliveries in women who have had previous cesarean deliveries to be driven by the financial interests of insurers rather than by genuine concern for the welfare of women and their infants. Although there is no doubt that a successful vaginal delivery after cesarean section is associated with less morbidity, a lower risk of mortality, and less expense than another cesarean delivery, there is still a risk of both maternal and perinatal disaster, as the case we presented amply demonstrated. We agree that not all of that mortality and catastrophic morbidity is avoidable by careful patient selection or by prompt treatment after diagnosis of a complication.
Initial enthusiastic reports of high rates of successful vaginal delivery after cesarean section with minimal risk1 have been followed by sobering reports of occasional disasters.2,3 This has led an early advocate of this method of delivery to publicly reconsider his approach to this issue4 from both medical and legal perspectives. Even the economic wisdom of encouraging vaginal delivery after cesarean section was recently called into question.5 Recognizing all of these issues, the American College of Obstetricians and Gynecologists is currently reexamining its position on this subject.
We thank Dr. Vega Vázquez for his thoughtful remarks. Since the fat emboli we found in the patient's lungs were not accompanied by hematopoietic elements of bone marrow, were also present in uterine vessels, and were present in the absence of rib or sternal fractures, we are confident that they represent amniotic fluid emboli and did not come from the bone marrow. Furthermore, respiratory failure rarely results from fat emboli to the lungs alone, without there also being emboli to the brain or kidney. In this case, there were no emboli to the brain or kidney.
5 ReferencesMichael F. Greene, M.D.
Eugene J. Mark, M.D.
Drucilla J. Roberts, M.D.
Massachusetts General Hospital, Boston, MA 021141
Phelan JP ,Clark SL ,Diaz F ,Paul RH . Vaginal birth after cesarean. Am J Obstet Gynecol 1987;157:1510-1515
Web of Science | Medline2
Chazotte C ,Cohen WR . Catastrophic complications of previous cesarean section. Am J Obstet Gynecol 1990;163:738-742
Web of Science | Medline3
Scott JR . Mandatory trial of labor after cesarean delivery: an alternative viewpoint. Obstet Gynecol 1991;77:811-814
Web of Science | Medline4
Phelan JP. VBAC — time to reconsider? OBG Management. November 1996:62-8.
5
Clark SL ,McClellan V ,Scott JR ,Burton DA ,Porter TF . Is VBAC less expensive than repeat cesarean? Am J Obstet Gynecol 1998;178:S31-S31 abstract.
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