Grand Rounds

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

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

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

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

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

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