No reproductive advantage with single- vs. double-layer closure after cesarean section

Key takeaways:

• Single- vs. double-layer closure after cesarean section made no difference for future live birth rates.
• There was also no difference in pregnancy rate, fertility treatment, delivery modes or uterine rupture.

Researchers observed no superiority in future reproductive or obstetric outcomes with double-layer vs. single-layer uterine closure after a first cesarean section.

“There is currently no universally accepted evidence-based guideline regarding the technique for uterine closure after a cesarean section. ACOG does not provide a specific clinical guideline in this regard. However, the National Institute for Health and Care Excellence (NICE) guideline recommends the use of either a single-layer or double-layer uterine closure, depending on specific clinical circumstances,” Carry Verberkt, MD, PhD student in the department of obstetrics and gynecology at Amsterdam University Medical Center and Amsterdam Reproduction and Development at the University of Amsterdam, and colleagues wrote in the American Journal of Obstetrics and Gynecology. “The Enhanced Recovery After Surgery (ERAS) Society recommends double-layer closure, as it is believed to potentially reduce the risk of uterine rupture. Previous studies did study outcomes after single- vs. double-layer closure but most used the less optimal locking sutures, which are associated with higher niche prevalence, and these studies primarily focused on short-term outcomes.”

Verberkt and colleagues conducted a multicenter, double-blind, randomized controlled trial, the 2Close study, with data from 2,292 women who underwent their first cesarean section at 32 hospitals in the Netherlands from 2016 to 2018. Overall, 1,648 women completed the 3-year follow-up questionnaires. All women were randomly assigned to single-layer (n = 830) or double-layer (n = 818) closure of the uterine incision following the procedure.

The primary outcome was live birth rate at the 3-year follow-up, and secondary outcomes included pregnancy rate, fertility treatment needs, mode of delivery and obstetric and gynecologic complications.

Researchers observed no differences at 3 years in live birth rates between women who received single- vs. double-layer uterine closure following cesarean section. In addition, researchers also noted no differences in pregnancy rate, fertility treatment needs, mode of delivery or uterine ruptures in subsequent pregnancies between the two groups.

Both single- and double-layer uterine closure resulted in high rates of gynecologic symptoms such as spotting (30.1% and 32%, respectively), dysmenorrhea (47.6% and 49%, respectively) and sexual dysfunction using Female Sexual Function Index scores (23.2 and 23, respectively).

“Based on our results, we propose that surgeons can choose their preferred closure technique in terms of single- or double-layer closure, using non-locking sutures,” the researchers wrote. “Future studies should incorporate a more comprehensive power analysis for obstetric outcomes and an extended follow-up to gain more insight into gynecological complaints and to elucidate the need for interventions.”