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Correction
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McMahon et al.,
Correction
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Paul,
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We think that the outcomes should have been analyzed according to whether the woman had had a previous vaginal delivery.2 In our hospital in 1995, for example, 11 of the 166 women (6.6 percent) who had previously delivered vaginally and had a trial of labor for a subsequent pregnancy underwent emergency cesarean section, as compared with 63 of the 209 women (30.1 percent) who had not had a previous vaginal delivery.
The results of a multicenter study conducted from 1986 through 1992 may not be applicable to an individual woman's circumstances in other hospitals in 1997. Ideally, the decision about the type of delivery should be shaped by the recent results in the hospital where the woman plans to deliver her baby. We believe that if women are carefully selected for a trial of labor and supervised closely, the risk of serious complications can be minimized and a successful outcome achieved.
Michael J. Turner, M.R.C.O.G.
Orla McNally, F.R.C.S.I.
François Gardeil, M.D.
Coombe Women's Hospital
Dublin 8, Ireland
References
Oren Fruchter, M.D.
29 Greenbaum St.
Haifa 34987, Israel
References
Although the authors provide a detailed account of the complications in both groups, they provide no information concerning the outcome of women without complications, even though these women constituted over 90 percent of each study group. No data are presented, for example, about the length of hospitalization, the duration of convalescence, or postpartum analgesic-drug therapy in the two groups. Since most women who chose to have a trial of labor delivered vaginally and because an uncomplicated vaginal delivery typically has less associated morbidity (according to these criteria) than an uncomplicated cesarean section, one would expect these outcomes to favor a trial of labor. Focusing on complications ignores these important, if mundane, determinants of morbidity.
Notwithstanding these deficiencies, the finding that women undergoing a trial of labor have nearly twice the rate of major complications of those who have an elective second cesarean section demands our attention. However, the authors have skewed their data by considering operative injuries together with the catastrophic complications of uterine rupture and hysterectomy. In fact, more than three quarters of the major complications reported were operative injuries, and it is only the inclusion of these injuries in the cumulative rate of major complications that renders the differences between the groups statistically significant. Although injury to the bladder or laceration of a uterine artery is injurious to the surgeon's honor, it is not usually catastrophic to the woman, as long as it is recognized and managed appropriately.
Andre H. Saad, M.D.
54 Spring Hollow Rd.
Roslyn, NY 11576
Ralph W. Hale, M.D.
American College of Obstetricians and Gynecologists
Washington, DC 20024-2188
References
To the Editor: Turner et al. suggest that the outcomes be analyzed according to whether a woman had had a previous vaginal delivery, in addition to the single previous cesarean section that was the criterion for entry into the study. There were 781 women in the trial-of-labor group who had also had a previous vaginal delivery. These women were at a decided advantage for having a successful trial of labor, a finding similar to that of Turner and his colleagues. In addition, as shown in Figure 1 of our article, morbidity as a function of increasing parity was greater in the group that underwent an elective second cesarean section than in the trial-of-labor group.
Fruchter calls attention to the risk associated with the use of oxytocin to induce labor and augment abnormal labor in women who have had a previous cesarean section. The data base used in our study did not include details about the timing, dosage, or duration of oxytocin administration. We therefore cannot determine the role of oxytocin in the deliveries of the women we studied. However, we agree that in women who have had a previous cesarean section, labor must be monitored closely and the use of oxytocin to induce or augment labor prescribed with caution.
Saad notes that no data were included about outcomes for women without complications. The outcome variables in the study were complications of delivery; the group of women without such complications was the basis for the odds ratio. Prolonged length of stay, prolonged convalescence, and postpartum analgesic-drug therapy are usually a result of complications of delivery, not the other way around, as suggested by Dr. Saad. We realize that there was possible bias in combining operative injury with hysterectomy and uterine rupture in a single category for data analysis. Consequently, the operative injuries included in this category were confined to those that were serious extensions of uterine incisions or injuries to adjacent organs that would potentially involve long-term morbidity or prohibit future vaginal deliveries.
We would also like to correct three errors in our article. On page 692 the sentence that begins 13 lines from the bottom of the left-hand column should have read, "Women 35 years old or older were less likely than others to require a cesarean section after a trial of labor." The phrase "A maternal age of 35 years or more" on line 10 of the left-hand column of page 694 should have been deleted. The first line of text on page 695 should have read, "if they were 35 years of age or older."
Michael J. McMahon, M.D., M.P.H.
Edwin R. Luther, M.D.
Watson A. Bowes, Jr., M.D.
University of North Carolina School of Medicine
Chapel Hill, NC 27599-7570
Richard H. Paul, M.D.
University of Southern California School of Medicine
Los Angeles, CA 90033
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