I want to congratulate Drs Oakes and Fisseha for their elegant presentation. The authors presented an incidental case (with excellent pictures) of an attenuated (dehiscence) uterine scar in a nonpregnant uterus, 13 months after a cesarean surgery. Although their case is a very short communication, it has the potential to open discussion on a larger picture.

After reading this article one must wonder: (1) How many women, unknowingly, are walking around with similar attenuated lower uterine segment and planning to become pregnant? (Important question because the incidence of uterine rupture is “low,”quoted to be approximately 1%, but, when it happens, it becomes 100% for the woman involved). (2) Why is the healing of a low segment uterine scar after a cesarean section delivery not always optimal? (3) Should every patient who is pregnant, with a prior cesarean delivery, be routinely evaluated for uterine scar “integrity”? If the answer is “Yes,” then, what is the best method? (ultrasonography in the presented case–a nonpregnant uterus–clearly was not helpful). Could ultrasonography or the magnetic resonance imaging of a pregnant uterus be of better value? If “Yes,” it should become “standard of care” before deciding for an attempt at vaginal birth after cesarean delivery? (4) Will this presented case affect in any way the “pendulum” in the daily practice of obstetrics and gynecology? “Once a cesarean section, always a cesarean section” vs the recommendation for vaginal birth after cesarean delivery?

Thank you, Drs Oakes and Fisseha, for your “short” presentation with the potential to trigger “big” questions that can impact the daily practice of obstetrics and gynecology.