European Journal of Obstetrics & Gynecology and Reproductive Biology, 45 (1992) 185-186
I85
0 1992 Elsevier Science Publishers B.V. All rights reserved 0028-2243/92/$05.00 EUROBS 01379
Routine previous cesarean scar exploration following successful vaginal delivery. Is it necessary? Samuel Lurie, Zion Hagay, Reinaldo
Goldschmit
and Vaclav Insler
Department of Obstetrics and Gynecology Kaplan Hospital (Affiliaied to the Medical School of the Hebrew Uni~ersiry and Hadussah, Jesusalem), Rehouot, Israel
Accepted for publication 1 April 1992
Summary Among the 960 women who successfully delivered by vaginal route after previous cesarean section, 10 (1.04%) had complete lower segment scar rupture over a 9 year period. All were sufficiently symptomatic in order to suspect a ruptured uterus prior to scar exploration. We conclude that lower uterine segment palpation should be reserved only for symptomatic patients. Uterine rupture; Cesarean section; Pregnancy complication
Introduction
Patients and Methods
It is a generally accepted practice, that patients with a previous cesarean section are allowed a trial of vaginal delivery during subsequent labor [ll. Although incidence of dehiscence of a previous low transverse uterine incision is extremely uncommon and most of them are asymptomatic 121,there still remains anxiety about advent of frank uterine rupture. In contrast to many European centers, where the lower uterine segment is not examined after successful vaginal delivery [2], routine exploration of the lower uterine segment remains a common practice in the United States [1,2]. We performed a retrospective analysis to assess the necessity of routine exploration of lower uterine segment in patients with successful vaginal deliveries after previous cesarean section.
We retrieved the labor and delivery records of our department’s delivery ward between 1 January 1983 and 31 December 1991. During that period we had 41,246 deliveries of which 2003 (4.9%) involved patients with a previous cesarean section. Vaginal delivery was successful in 960 (47.9%). Previous scar exploration was performed in all of them, usually under intravenous narcotic anesthesia to reduce pain associated with the manipulation. Uterine rupture was considered as a separation of the entire wall of the uterus including the decidua, myometrium and serosa.
Correspondence
to: S. Lurie, M.D., Department of Obstetrics & Gynecology, Kaplan Hospital, 76100 Rehovot, Israel.
Results Among the 960 women who accomplished vaginal delivery after previous cesarean section 10 (1.04%) had complete lower segment scar rupture as confirmed by operative exploration. All ten were symptomatic, and the diagnosis of uterine rupture was suspected prior to scar revision.
186
Suprapubic pain was found in four patients, fetal bradycardia in four, excessive hemorrhage in three, and atonic uterus in one. There were no maternal or perinatal deaths. In nine women a simple repair of the ruptured scar was performed, and one underwent a total abdominal hysterectomy. We had another case of uterine rupture in a patient with a previous cesarean section who was operated for indication of cephalopelvic disproportion (CPD) and a large hematoma in the broad ligament with complete separation of uterine wall was found. Thus we have found a scar rupture rate of 11 in 2003 (0.54%) of all patients with previous cesarean section. Discussion
Since Ames’s appraisal in 1881 [3], rupture of the uterus still remains one of the major catastrophic events in modern obstetrics [1,4-61. Although trial of vaginal delivery in patients with low transverse cesarean scar most often is a safe and desirable option [1,2,5,7], several areas of management of patients with previous cesarean section remain controversial [1,2]. One of the controversies concerns routine previous cesarean scar exploration following vaginal delivery. The reported incidence for uterine rupture in patients with a previous cesarean scar in recent studies is 0.17-1.4% [4-71. In our series of 2003 patients with a previous cesarean section, we had an 0.54% incidence of ruptured uterus. Among the 960 women who accomplished vaginal delivery ten had a rupture of uterine scar. All ten cases of uterine rupture were sufficiently symptomatic that a separation of scar prior to scar exploration was suspected. It follows that, in our series, for each case of uterine scar separation 96
patients with previous cesarean section underwent unnecessary scar exploration. The large bulk of 950 asymptomatic patients that underwent unnecessary scar exploration were in addition exposed to risks associated with anesthesia and manual manipulation. The vast majority of patients with true uterine rupture are symptomatic [1,5,6]. In view of our data, and since most scar separations are incomplete and hence repair is not advocated [2], we suggest that the lower uterine segment be examined only in symptomatic patients. Routine expforation of previous cesarean scar following successful vaginal delivery is, therefore, unnecessary. The question arises what symptoms necessitate uterine scar exploration. We believe that excessive vaginal bleeding and/or persistent suprapubit pain represent indication for previous scar exploration following vaginal delivery. References Cunningham FG, Mac Donald PC, Gant NF. Williams Obstetrics. 18th ed. Norwalk, Connecticut/San Mateo, California: Appleton & Lange 1989;441-445. Clark SL. Rupture of the scarred uterus. Obstet Gynecol Clin N Am 1988;15:737-744. Ames RPM. Rupture of the uterus. Am J Obstet Gynecol 1881;1:361. Eden RD, Parker RT, Gall SA. Rupture of the pregnant uterus: a 53-year review. Obstet Gynecol 1986;68:671-674. Chazotte C, Cohen WR. Catastrophic complications of previous cesarean section. Am J Obstet Gynecol 1990;163:738742. Jones RO, Nagashima AW, Hartnett-Goodman MM, Goodlin RC. Rupture of low transverse cesarean scars during trial of labor. Obstet Gynecol 1991:77:81.5-817. Flamm BL, Newman LA, Thomas SJ, Fallon D, Yoshida MM. Vaginal birth after cesarean delivery: results of a 5-year multicenter collaborative study. Obstet Gynecol 1990;76:750-754.
I85
0 1992 Elsevier Science Publishers B.V. All rights reserved 0028-2243/92/$05.00 EUROBS 01379
Routine previous cesarean scar exploration following successful vaginal delivery. Is it necessary? Samuel Lurie, Zion Hagay, Reinaldo
Goldschmit
and Vaclav Insler
Department of Obstetrics and Gynecology Kaplan Hospital (Affiliaied to the Medical School of the Hebrew Uni~ersiry and Hadussah, Jesusalem), Rehouot, Israel
Accepted for publication 1 April 1992
Summary Among the 960 women who successfully delivered by vaginal route after previous cesarean section, 10 (1.04%) had complete lower segment scar rupture over a 9 year period. All were sufficiently symptomatic in order to suspect a ruptured uterus prior to scar exploration. We conclude that lower uterine segment palpation should be reserved only for symptomatic patients. Uterine rupture; Cesarean section; Pregnancy complication
Introduction
Patients and Methods
It is a generally accepted practice, that patients with a previous cesarean section are allowed a trial of vaginal delivery during subsequent labor [ll. Although incidence of dehiscence of a previous low transverse uterine incision is extremely uncommon and most of them are asymptomatic 121,there still remains anxiety about advent of frank uterine rupture. In contrast to many European centers, where the lower uterine segment is not examined after successful vaginal delivery [2], routine exploration of the lower uterine segment remains a common practice in the United States [1,2]. We performed a retrospective analysis to assess the necessity of routine exploration of lower uterine segment in patients with successful vaginal deliveries after previous cesarean section.
We retrieved the labor and delivery records of our department’s delivery ward between 1 January 1983 and 31 December 1991. During that period we had 41,246 deliveries of which 2003 (4.9%) involved patients with a previous cesarean section. Vaginal delivery was successful in 960 (47.9%). Previous scar exploration was performed in all of them, usually under intravenous narcotic anesthesia to reduce pain associated with the manipulation. Uterine rupture was considered as a separation of the entire wall of the uterus including the decidua, myometrium and serosa.
Correspondence
to: S. Lurie, M.D., Department of Obstetrics & Gynecology, Kaplan Hospital, 76100 Rehovot, Israel.
Results Among the 960 women who accomplished vaginal delivery after previous cesarean section 10 (1.04%) had complete lower segment scar rupture as confirmed by operative exploration. All ten were symptomatic, and the diagnosis of uterine rupture was suspected prior to scar revision.
186
Suprapubic pain was found in four patients, fetal bradycardia in four, excessive hemorrhage in three, and atonic uterus in one. There were no maternal or perinatal deaths. In nine women a simple repair of the ruptured scar was performed, and one underwent a total abdominal hysterectomy. We had another case of uterine rupture in a patient with a previous cesarean section who was operated for indication of cephalopelvic disproportion (CPD) and a large hematoma in the broad ligament with complete separation of uterine wall was found. Thus we have found a scar rupture rate of 11 in 2003 (0.54%) of all patients with previous cesarean section. Discussion
Since Ames’s appraisal in 1881 [3], rupture of the uterus still remains one of the major catastrophic events in modern obstetrics [1,4-61. Although trial of vaginal delivery in patients with low transverse cesarean scar most often is a safe and desirable option [1,2,5,7], several areas of management of patients with previous cesarean section remain controversial [1,2]. One of the controversies concerns routine previous cesarean scar exploration following vaginal delivery. The reported incidence for uterine rupture in patients with a previous cesarean scar in recent studies is 0.17-1.4% [4-71. In our series of 2003 patients with a previous cesarean section, we had an 0.54% incidence of ruptured uterus. Among the 960 women who accomplished vaginal delivery ten had a rupture of uterine scar. All ten cases of uterine rupture were sufficiently symptomatic that a separation of scar prior to scar exploration was suspected. It follows that, in our series, for each case of uterine scar separation 96
patients with previous cesarean section underwent unnecessary scar exploration. The large bulk of 950 asymptomatic patients that underwent unnecessary scar exploration were in addition exposed to risks associated with anesthesia and manual manipulation. The vast majority of patients with true uterine rupture are symptomatic [1,5,6]. In view of our data, and since most scar separations are incomplete and hence repair is not advocated [2], we suggest that the lower uterine segment be examined only in symptomatic patients. Routine expforation of previous cesarean scar following successful vaginal delivery is, therefore, unnecessary. The question arises what symptoms necessitate uterine scar exploration. We believe that excessive vaginal bleeding and/or persistent suprapubit pain represent indication for previous scar exploration following vaginal delivery. References Cunningham FG, Mac Donald PC, Gant NF. Williams Obstetrics. 18th ed. Norwalk, Connecticut/San Mateo, California: Appleton & Lange 1989;441-445. Clark SL. Rupture of the scarred uterus. Obstet Gynecol Clin N Am 1988;15:737-744. Ames RPM. Rupture of the uterus. Am J Obstet Gynecol 1881;1:361. Eden RD, Parker RT, Gall SA. Rupture of the pregnant uterus: a 53-year review. Obstet Gynecol 1986;68:671-674. Chazotte C, Cohen WR. Catastrophic complications of previous cesarean section. Am J Obstet Gynecol 1990;163:738742. Jones RO, Nagashima AW, Hartnett-Goodman MM, Goodlin RC. Rupture of low transverse cesarean scars during trial of labor. Obstet Gynecol 1991:77:81.5-817. Flamm BL, Newman LA, Thomas SJ, Fallon D, Yoshida MM. Vaginal birth after cesarean delivery: results of a 5-year multicenter collaborative study. Obstet Gynecol 1990;76:750-754.
