Original Research ajog.

org

OBSTETRICS
Single versus double-layer uterine closure at cesarean:
impact on lower uterine segment thickness at
next pregnancy
Chantale Vachon-Marceau, MD; Suzanne Demers, MD, MSc; Emmanuel Bujold, MD, MSc; Stephanie Roberge, PhD;
Robert J. Gauthier, MD; Jean-Charles Pasquier, MD, PhD; Mario Girard, RT; Nils Chaillet, PhD; Michel Boulvain, MD, PhD;
Nicole Jastrow, MD

BACKGROUND: Uterine rupture is a potential life-threatening
complication during a trial of labor after cesarean delivery. Single-
layer closure of the uterus at cesarean delivery has been associ-
ated with an increased risk of uterine rupture compared with double-
layer closure. Lower uterine segment thickness measurement by
ultrasound has been used to evaluate the quality of the uterine scar
after cesarean delivery and is associated with the risk of uterine
rupture.
OBJECTIVE: To estimate the impact of previous uterine closure on
lower uterine segment thickness.
STUDY DESIGN: Women with a previous single low-transverse ce-
sarean delivery were recruited at 34
38 weeks’ gestation. Trans-
abdominal and transvaginal ultrasound evaluation of the lower uterine
segment thickness was performed by a sonographer blinded to clinical
data. Previous operative reports were reviewed to obtain the type of
previous uterine closure. Third-trimester lower uterine segment thickness
at the next pregnancy was compared according to the number of layers
sutured and according to the type of thread for uterine closure, using
weighted mean differences and multivariate logistic regression analyses.
RESULTS: Of 1613 women recruited, with operative reports available,
495 (31%) had a single-layer and 1118 (69%) had a double-layer closure.
The mean third-trimester lower uterine segment thickness was 3.3  1.3
mm and the proportion with lower uterine segment thickness <2.0 mm
was 10.5%. Double-layer closure of the uterus was associated with a
thicker lower uterine segment than single-layer closure (weighted mean
difference: 0.11 mm; 95% confidence interval [CI], 0.02 to 0.21 mm). In
multivariate logistic regression analyses, a double-layer closure also was
associated with a reduced risk of lower uterine segment thickness <2.0
mm (odd ratio [OR], 0.68; 95% CI, 0.51 to 0.90). Compared with synthetic
thread, the use of catgut for uterine closure had no significant impact on
third-trimester lower uterine segment thickness (WMD:
0.10 mm; 95%
CI,
0.22 to 0.02 mm) or on the risk of lower uterine segment thickness
<2.0 mm (OR, 0.95; 95% CI, 0.67 to 1.33). Finally, double-layer closure
was associated with a reduced risk of uterine scar defect (RR, 0.32; 95%
CI, 0.17 to 0.61) at birth.
CONCLUSION: Compared with single-layer closure, a double-layer
closure of the uterus at previous cesarean delivery is associated with a
thicker third-trimester lower uterine segment and a reduced risk of lower
uterine segment thickness <2.0 mm in the next pregnancy. The type of
thread for uterine closure has no significant impact on lower uterine
segment thickness.
Key words: cesarean, pregnancy, surgical technique, ultrasound,
uterine scar

T he rate of cesarean delivery is

increasing continuously and has
reached more than 30% in several
countries.1-3 This trend has been
enhanced by a decrease in the rates of
trial of labor after cesarean (TOLAC)
and vaginal birth after cesarean.1-4
Uterine rupture during TOLAC is asso-
ciated with a significant risk of neonatal
morbidity and mortality that can influ-
ence the choice of women and their
Cite this article as: Vachon-Marceau C, Demers S,
Bujold E, et al. Single versus double-layer uterine closure
at cesarean: impact on lower uterine segment thickness
at next pregnancy. Am J Obstet Gynecol
2017;217:65.e1-5.
0002-9378/$36.00
ª 2017 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ajog.2017.02.042
physician toward an elective repeat ce-
sarean (ERC).5-10 In contrast, repeated
cesarean deliveries expose women to
other obstetrical complications,
including placenta praevia and placenta
accreta, need for blood transfusions,
hysterectomy, as well as urinary tract and
bowel injuries during surgery.11 Each
year, millions of pregnant women with
previous cesarean delivery are facing the
difficult choice between TOLAC and
ERC.
Numerous risk factors for uterine
rupture have been reported. Among
these, uterus closure at cesarean delivery
is a factor that is potentially modifiable.
Single-layer closure of the uterus at ce-
sarean has been associated with a 3- to 5-
fold increase risk of uterine rupture
during subsequent TOLAC compared
with double-layer closure, particularly
when the single-layer is locked.10,12,13
Most studies, however, were retrospec-
tive or used a small number of events and
therefore, few recommendations can be
drawn.10,12,14,15 Two randomized trials
compared the 2 types of closure for the
risk of uterine rupture at the next preg-
nancy: Chapman et al16 reported no
uterine rupture and 1 case of uterine scar
dehiscence after TOLAC among 70
women with single-layer and neither
uterine rupture nor scar dehiscence after
TOLAC in 75 women randomized to
double-layer closure; in addition, the
CORONIS collaborative group reported
1 (0.06%) case of uterine rupture of 1610
births after single-layer closure and 2
(0.12%) cases of 1624 births after
double-layer closure in the 3-year
follow-up of their multicenter random-
ized trial.17 Those 2 randomized trials

JULY 2017 American Journal of Obstetrics & Gynecology 65.e1

Original Research
TABLE 1
Population characteristics according to the number of layer for uterus closure at the previous cesarean delivery
Characteristic
Maternal age, y
Body mass index, kg/m2
Previous cesarean during labor
Type of suture (synthetic)
Interdelivery interval, mo
Gestational age at ultrasound, wk
Centers
CHU de Québec
Sainte-Justine Hospital
CHU de Sherbrooke
Hôpitaux Universitaire de Genève
Continuous variable are reported as median (interquartile range).
NS, not significant.
Vachon-Marceau et al. Uterine closure and lower uterine segment thickness. Am J Obstet Gynecol 2017.
did not have sufficient power to detect
moderate difference in the risk of uterine
rupture between the 2 types of uterine
closure.
Lower uterine segment thickness
(LUST) measurement by ultrasound has
been used to evaluate the quality of the
uterine scar after cesarean delivery and is
associated with the risk of uterine
rupture: a thinner measurement is
associated with a greater risk of uterine
scar dehiscence or uterine rupture dur-
ing TOLAC.18-21 LUST decreases with
gestational age from 5.1  1.4 mm at 20
weeks to 3.6  1.3 mm at 30 weeks and
2.3  0.6 mm at 40 weeks of gestation in
women without previous cesarean de-
livery.22 In women with a previous ce-
sarean delivery, a value <2.0 mm
measured between 35 and 38 weeks has
been associated repetitively with a
greater risk of uterine rupture or scar
dehiscence compared with a measure-
ment >2.0 mm.19,20,22 Rozenberg et al
observed that the introduction of LUST
measurement in clinical practice led to a
significant reduction of uterine scar de-
fects whereas we recently reported that
the use of LUST was associated with a
low risk of uterine rupture during
TOLAC.19,23 We also observed a strong
relationship between a thin LUST and
65.e2 American Journal of Obstetrics & Gynecology JULY 2017
OBSTETRICS
Single-layer, n ¼ 495 Double-layer, n ¼ 1118
32 (29e35)
29 (26e33)
347/492 (71%) 782/1116 (70%)
369/478 (77%) 697/1084 (64%)
40 (29e63)
36.9 (36.3e37.3)
179 (36%)
34 (7%)
7 (1%)
275 (56%)
the risk of uterine scar defect at ERC.
Third-trimester LUST in the subsequent
pregnancy could therefore be used as a
surrogate marker for uterine scar heal-
ing, whereas a very thin LUST could be
used as a surrogate marker for uterine
scar defect. We aimed to evaluate the
impact of single- vs double-layer closure
of cesarean delivery on third-trimester
LUST measured in the next pregnancy.
Materials and Methods
We performed a secondary analysis of a
multicenter prospective cohort study
that was conducted between April 2009
and June 2013 in 4 hospitals: Centre
Hospitalier de l’Université Laval,
Québec, Canada; Centre Hospitalier
Sainte-Justine, Montréal Canada; Centre
Hospitalier Universitaire Fleurimont,
Sherbrooke, Canada; and Hôpitaux
Universitaires de Genève, Geneva,
Switzerland.23 Women with singleton
pregnancy and documented previous
single low-transverse cesarean who were
contemplating vaginal birth after cesar-
ean were recruited between 34 weeks and
0 days and 38 weeks and 6 days of
gestation. Each woman underwent
transabdominal and transvaginal ultra-
sound for measurement of LUST by a
trained sonographer or midwife blinded
ajog.org
P value
31 (28e34) NS
29 (26e32) NS
NS
<.001
30 (23e41) <.001
36.7 (36.1e37.1) NS
794 (71%) <.001
261 (23%)
49 (4%)
14 (1%)
to all clinical data and under supervision
of a maternal-fetal medicine
specialist.18,24 Measurement was per-
formed at least 6 times, with a minimum
of 3 transabdominal and 3 transvaginal
measurements, and the thinnest lower
uterine segment (LUS) value was
retained.
Demographic information, medical
and reproductive history, as well as fea-
tures of the previous cesarean delivery
were collected after informed consent
was obtained from the participants.
Participants with available uterine
closure technique at previous cesarean
delivery from either the operative
reports or medical files were included.
Uterine closure was reported as single-
or double-layer closure and type of
suture was reported as synthetic or
chromic catgut. In cases in which a
different type of suture was used for the
first and the second layer, we considered
the type of suture used for the first layer.
The institutional ethics committee in
each center approved the study, and each
woman signed an informed consent
form.
We reported the distribution of par-
ticipant’s characteristics in both groups
using nonparametric analyses. We
compared the mean difference with 95%
ajog.org
confidence intervals (CIs) of third-
trimester LUST and the rates of LUST
<2.0 mm between the groups (single vs
double layer; synthetic vs catgut suture)
using the Student t test and the c2 test
weighted by center. Multivariate linear
regression analyses and multivariate lo-
gistic regression analyses were then used
to evaluate the impact of uterine closure
technique on LUST and LUST <2.0 mm
after adjustment for potential con-
founding factors including an inter-
delivery interval (time between the
cesarean delivery and the expected de-
livery date of the next pregnancy) <18
months, a previous cesarean performed
before labor, before 37 weeks (preterm
cesarean); advanced maternal age (35
years old), obesity (body mass index 30
kg/m2), and the center. Statistical ana-
lyses were conducted with SPSS software
(version 22.0; SPSS Inc, Chicago, IL),
and P < .05 was considered significant.
The sample size was limited to the
number of women recruited in the
original study.
Results
A total of 1856 women originally were
recruited, and they had a mean third-
trimester LUST of 3.3  1.3 mm. Of
these patients, we were able to obtain
details on uterine closure technique at
previous cesarean for 1613 (87%)
women with a similar third-trimester
LUST 3.3  1.3 mm and with a rate
of LUST <2.0 mm of 10.5%. A single-
layer closure was performed in 495
(31%) patients, whereas 1118 (69%)
patients had a double-layer closure.
Table 1 reports the characteristics of the
population according to uterine
closure. We observed that women with
a previous single-layer closure of the
uterus were more likely to have a
closure that used a synthetic suture and
to have a longer interdelivery interval.
The frequency of single and double-
layer uterus closure (Table 1) and the
use of catgut thread (from 0% to
43.1%) varied significantly between
centers (both with P < .001).
Double-layer closure at previous ce-
sarean was associated with a thicker
LUS than single-layer closure in each
center (from 0.1 to 1.0 mm) for a
OBSTETRICS
TABLE 2
Multivariate logistic regression analysis of potential factors associated with
third-trimester LUST <2.0 mm in the next pregnancy
Variables Odd ratioa
Double-layer closure 0.68
Chromic catgut 0.95
Interdelivery interval <18 mo 2.92
Previous cesarean during labor 0.28
Previous cesarean before 37 weeks 0.77
Maternal age >35 y 0.92
Body mass index >30 kg/m 2
0.74
LUST, lower uterine segment thickness.
a
Weighted by center.
Vachon-Marceau et al. Uterine closure and lower uterine segment thickness. Am J Obstet Gynecol 2017.
weighted mean difference (WMD) of
0.11 mm (95% CI 0.02 to 0.21 mm,
P ¼ .02). After adjustment for con-
founding factors with multivariate
linear regression analysis, we observed
that a double-layer closure remained
associated with a significant thicker
third-trimester LUS in the next preg-
nancy (þ0.14 mm; 95% CI, 0.04 to
0.24 mm; P ¼ .005). Moreover, the rate
of third-trimester LUST <2.0 mm was
smaller with double-layer closure in
comparison with single-layer (8.5% vs
11.0%, P ¼ .03) and the association
remained significant after adjustment
for confounding factors in multivariate
regression analysis (Table 2).25
We observed that a previous cesarean
during labor was protective for LUST
<2.0 mm. We repeated the analysis ac-
cording to the presence or absence of
labor at previous cesarean. In women
with previous pre-labor cesarean, we
observed that double-layer closure of the
uterus remained associated with a thicker
third-trimester LUS (WMD, 0.21 mm;
95% CI, 0.06 to 0.36 mm; P <.001) and a
lower risk of LUST <2.0 mm (odd ratio,
0.57; 95% CI, 0.38 to 0.85) after adjust-
ment for confounding factors. In women
with previous cesarean performed during
labor, double-layer closure was associated
with a thicker third-trimester LUS
(WMD, þ0.13 mm; 95% CI, 0.003 to
0.25 mm; P ¼ .045) but no more asso-
ciated with the rate of LUST <2.0 mm
(odd ratio, 0.72; 95% CI, 0.48 to 1.07).
JULY 2017 American Journal of Obstetrics & Gynecology
Original Research
95% confidence interval P value
0.51e0.90 <.01
0.67e1.33 .75
1.70e5.01 <.001
0.21e0.36 <.001
0.50e1.19 .24
0.68e1.23 .56
0.56e0.98 .04
Compared with synthetic thread, the
use of catgut for uterine closure had no
significant impact on third-trimester
LUST (WMD,
0.10 mm; 95%
CI,
0.22 to 0.02 mm) or LUST <2.0
mm after adjustment for confounding
factors (Table 2).
We observed that an interdelivery in-
terval <18 months; a body mass index
>30 kg/m2; and a cesarean delivery
performed before labor were all factors
associated with an increased risk of
LUST <2.0 after adjustment for
confounders.
Obstetrical outcomes were available
for 1607 participants (Table 3). We
observed that women with double-layer
closure were slightly more likely to un-
dergo a TOLAC and less likely to have a
uterine scar dehiscence during a repeat
cesarean delivery, whether the cesarean
was performed after a TOLAC or elec-
tively. Double-layer closure was associ-
ated with a reduced risk of uterine scar
defect (RR, 0.32; 95% CI, 0.17 to 0.61) at
birth.
Comment
We observed that double-layer closure of
the uterus at previous cesarean is asso-
ciated with a thicker third-trimester LUS
and with a lower risk of LUST <2.0 mm
in the next pregnancy compared
with single-layer closure. Moreover, we
observed no significant impact of the
type of suture (chromic catgut vs syn-
thetic) on third-trimester LUST. Those
65.e3
Original Research
TABLE 3
Rates of VBAC and uterine scar defects according to uterus closure
TOLAC
Vaginal birth
Symptomatic uterine rupture
Asymptomatic uterine rupture
Scar dehiscence/cesarean
Elective repeat cesarean
Uterine scar dehiscence
Uterine scar defect/all participants
Uterine scar defect/cesarean
NS, not significant; TOLAC, trial of labor after cesarean; VBAC, vaginal birth after cesarean.
Vachon-Marceau et al. Uterine closure and lower uterine segment thickness. Am J Obstet Gynecol 2017.
observations suggest that double-layer
closure could improve uterine scar
healing and reduce the risk of uterine
scar defect in the next pregnancy.
Our findings are in agreement with a
previous meta-analysis that reported a
lower risk of uterine rupture during
TOLAC in women with a double-layer
closure and recent randomized trials
that observed a thicker remaining myo-
metrium more than 6 months after
cesarean delivery with double-layer
closure compared with single-layer
closure.13,26,27 A meta-analysis of ran-
domized trials evaluated the role of uter-
ine closure on uterus scar healing assessed
in the following weeks or months after
cesarean and reported that single-layer
closure (
2.6 mm; 95% CI,
3.1
to
2.1; P < .001) was associated with a
thinner residual myometrium than
double-layer closure.28 Two other studies
evaluated the role of uterine closure on
third-trimester LUST value.29,30 In both
cases, the authors observed no significant
difference of LUSTmeasurement between
the 2 types of uterine closure, but both
studies were limited by their size (233 and
377 participants, respectively) and by the
absence of adjustment for potential con-
founding factors.
The current study demonstrates, as
suggested by different authors, that a
previous cesarean delivery performed
before labor is associated with a thinner
third-trimester LUS compared with a
65.e4 American Journal of Obstetrics & Gynecology JULY 2017
OBSTETRICS
Single-layer, Double-layer,
n ¼ 495 n ¼ 1112
244 (49%) 617 (56%)
160/244 (66%) 429/617 (70%)
0 0
2/244 (0.8%) 1/617 (0.2%)
9/84 (10.7%) 6/188 (3.2%)
251 (51%) 495 (44%)
10 (4.0%) 8 (1.6%)
21 (4.2%) 15 (1.3%)
21/335 (6.3%) 15/683 (2.2%)
cesarean performed during labor.29,30
This finding is also in agreement with
the study of Algert et al,31 who showed a
greater risk of uterine rupture when the
previous caesarean was performed
before labor. Moreover, when the cesar-
ean is performed before labor, a double-
layer suture could have even a more
positive impact by reducing the impaired
healing of the scar compared with single-
layer closure. This new information
could help understanding the relative
heterogeneity in the results of previous
studies that evaluated the impact of
uterine closure on the risk of impaired
scar healing or uterine scar defects. In
addition, it could facilitate the work of
obstetricians who are performing the
surgery: when the cesarean is performed
before labor, the LUS typically is thicker
than when it is performed in advanced
labor, and it is usually easy to perform a
first-layer suture avoiding the decidua
followed by a second layer for the
approximation of the myometrium. In
contrast, it is sometimes difficult to
identify these two layers of the LUS when
it gets thinner by repetitive uterine
contractions during labor. Thus, per-
forming a double-layer closure may be
less important in advanced labor. Finally,
our results confirmed those from previ-
ous studies that reported a greater risk of
uterine rupture with a short inter-
delivery interval and especially when the
interval is shorter than 18 months.32-34
ajog.org
The current study has some limita-
tions. The choice of uterus closure could
have been influenced by factors that were
not available for adjustment in our an-
P value alyses. Moreover, it is possible that it is
.02 not the number of layers per se that in-
fluences uterine scar healing but other
NS
techniques related to the number of
NS layers. For example, it has been suggested
NS that inclusion of the decidua into the
<.001 suture could be a significant risk factor
for impaired healing, uterine scar defect,
.02
and its consequences, such as placenta
.046 accreta and uterine rupture.28,35-37 In
<.001 North America, single-layer closure
<.001 combining the inclusion of the decidua
and locking of the suture is common.38
Those surgical details were not
collected and therefore, we cannot
speculate on which of these specific
characteristics of single-layer closure
would be responsible for impaired
healing and we cannot speculate on the
role of adding a second-layer on an
unlocked first-layer excluding the
decidua for example. Finally, we were
not able to collect the type of double-
layer closure (vertical mattress or
Lambert suture closure) because of the
heterogeneity between operative reports.
The current study has also several
strengths, including the large sample
size, which allowed adjustment for
several factors, the measurement of
LUST performed by a technician blinded
to the previous surgical technique, and
the fact that our results are concordant
whether LUST is reported as a contin-
uous or dichotomic variable. Finally, our
observations that uterine scar defect was
more frequent at ultrasound are
concordant with our observations at the
time of delivery.
In conclusion, the current study sup-
ports the use of double-layer suture of
the uterus at cesarean, especially when it
is performed before labor, to optimize
uterine scar healing. This technique
could lead to a reduction of uterine scar
defects during a TOLAC. n
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Author and article information
From the Department of Obstetrics & Gynaecology,
Faculty of Medicine, Université Laval, QC, Canada (Drs
Vachon-Marceau, Demers, Bujold, and Chaillet); Centre
de recherche du CHU de Québec-Université Laval,
Québec, QC, Canada (Drs Demers, Bujold, Roberge, and
Chaillet and Mr Girard); Department of Obstetrics & Gy-
naecology, Faculty of Medicine, Université de Montréal,
Montréal, QC, Canada (Dr Gauthier); Department of Ob-
stetrics & Gynaecology, Faculty of Medicine, Université de
Sherbrooke, Sherbrooke, QC, Canada (Dr Pasquier); and
Department of Obstetrics & Gynaecology, Faculty of
Medicine, Hôpitaux Universitaires de Genève, Université
de Genève, Geneva, Switzerland (Drs Boulvain and
Jastrow).
Received Dec. 5, 2016; revised Feb. 11, 2017;
accepted Feb. 24, 2017.
The authors report no conflict of interest.
This study was funded by the Canadian Institutes of
Health Research (CIHR operating grant #210974), the
Geneva University Hospitals (PRD #09-II-28), and the
Jeanne et Jean-Louis Levesque Perinatal Research Chair
at Université Laval, Canada. E.B. hold a Research’s salary
award from the Fonds de la Recherche du Québece
Santé and Stephanie Roberge hold a Research’s salary
award from CIHR.
Corresponding author: Nicole Jastrow, MD. nicole.
jastrowmeyer@hcuge.ch
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