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#Grand Rounds

Does Adding a 2nd Layer to Uterine Closure of a Cesarean Section Alter Outcomes?

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INTRODUCTION: 

  • There are randomized studies evaluating the addition of the second layer, but generally following locked suture technique  
  • Bennich et al. (Ultrasound Obstet Gynecol, 2016) investigated the impact of adding a second layer to a single unlocked closure of a cesarean uterine incision on residual myometrial thickness (RMT) as a proxy for uterine rupture risk 

METHODS: 

  • Randomized double-blind controlled trial (2008-2013) 
  • Nulliparous women > 37 weeks scheduled for cesarean section  
  • Women randomized to 
    •  Single-layer technique (continuous) 
    •  Double-layer technique 2nd layer (continuous – up to 3 separate sutures for hemostasis if needed)  
  • At discharge 
    • Transabdominal ultrasound  
  • At 5 months  
    • Saline contrast sonohysterography at a minimum of 5 months postpartum 
  • Ultrasound examiners were blinded to closure technique 

RESULTS: 

  • Single layer n= 35; double-layer n= 38 
  • No difference in age, BMI or perioperative characteristics (e.g., duration of surgery) between groups  
  • When comparing groups, there were no difference in the RMT whether at discharge (mean ± SD, 20.2 ± 8.0 mm vs 21.0 ± 9.7 mm) or after 5 months postpartum (5.7 ± 2.9 mm vs 5.7 ± 2.2 mm) 
    • RMT was approximately half that of the normal myometrium at both examinations 
  • There were also no differences in gestational age at delivery, duration of surgery and perioperative blood loss 

CONCLUSION: 

  • Double-layer closure of C-section incision does not increase RMT compared with single-layer closure when an unlocked technique is used 
  • Some previous studies demonstrated a larger RMT with double-layer used locked first-layer 
  • Authors suggest that unlocked technique for the first-layer is at least as good as double layer, and a first-layer locking technique may result in reduced RMT and possible increase risk for rupture 

Learn More – Primary Sources

Impact of adding a second layer to a single unlocked closure of a Cesarean uterine incision: randomized controlled trial 

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Related ObG Topics:

Suture or Staple for Cesarean Section Skin Closure?
Which is the Better Suture to Prevent C-Section Wound Complications? 
C-Section Skin Closure: Glue or Subcuticular Sutures?
Do Different Surgical C-Section Techniques Affect Outcomes?

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