Uterine Closure Technique Research Articles

Comparing Cesarean Scar Defect Incidence After Locked and Unlocked Repair Methods Among Primiparous Patients: A Randomized Double-Blinded Trial.

To compare residual myometrial thickness (RMT) and cesarean scar defect (CSD) development after cesarean section using double-layer locked and unlocked closure techniques. We conducted a randomized double-blinded trial comparing double-layer locked and unlocked uterine closure techniques following cesarean section in primiparous women. The locked technique involved continuous suturing of the full myometrial thickness in the first layer, followed by back-and-forth needle maneuvering on both sides of the incision for the second layer. The unlocked method included running suturing of two-thirds of the myometrial thickness in the first layer, followed by suturing the upper half of the myometrial thickness in the second layer. Transvaginal ultrasonography was performed one year post-cesarean section, with RMT as the primary outcome and scar depth and width as secondary outcomes. Independent t-test and Chi-square test were utilized for statistical analysis. All 30 patients from the locked and 26 from the unlocked group in the follow-up were diagnosed with CSD (scar depth>2mm). The mean RMT for the unlocked and locked groups were 4.44±1.07mm and 4.12±0.48mm, respectively, showing no significant difference (p =0.14). There was also no significant difference in mean scar width between the locked and unlocked groups (3.68±1.44mm vs. 3.95±1.00mm, p =0.42). However, the mean scar depth was higher in the unlocked group (3.77±1.11 mm vs. 3.16±1.1mm, p =0.04). We have found no significant differences in the RMT and CSD prevalence between two-layered locked and unlocked uterine closure techniques, while the scar depth was greater in the unlocked group. Nonetheless, future randomized trials implementing larger sample sizes are required to precisely compare the outcomes of the double-layer locked and unlocked uterine suturing techniques.

The Effects of Uterine Closure Techniques Single Layer Locking, Modified Lembert, and Laterally Continuing Suture on Uterine Scar Development: A Cohort Research

The Effects of Uterine Closure Techniques Single Layer Locking, Modified Lembert, and Laterally Continuing Suture on Uterine Scar Development: A Cohort Research

Single-layer vs double-layer uterine closure during cesarean delivery: 3-year follow-up of a randomized controlled trial (2Close study)

BackgroundThe rising rate of cesarean sections (CS) has led to an increased incidence of long long-term complications, including niche formation in the uterine scar. Niche development is associated with various gynecological complaints and complications in subsequent pregnancies, such as uterine rupture and placenta accreta spectrum disorders. Although uterine closure technique is considered a potential risk factor for niche development, consensus on the optimal technique remains elusive. ObjectiveWe aim to evaluate the effect of single- versus double-layer closure of the uterine incision on live birth rate at a 3-year follow-up with secondary objectives focusing on gynecological, fertility and obstetric outcomes at the same follow-up. Study DesignA multicenter, double-blind, randomized controlled trial was performed at 32 hospitals in the Netherlands. Women ≥18 years undergoing a first CS were randomly assigned (1:1) to receive either single-layer or double-layer closure of the uterine incision. The primary outcome of the long-term follow-up was the live birth rate with secondary outcomes including pregnancy rate, the need for fertility treatment, mode of delivery, and obstetric and gynecologic complications. This trial is registered on the International Clinical Trials Registry Platform www.who.int (NTR5480; trial finished). ResultsBetween 2016 and 2018, the 2Close study randomly assigned 2292 women, with 830/1144 and 818/1148 responding to the 3-year questionnaire in the single-layer and double-layer closure. No differences were observed in live birth rates, also no differences in pregnancy rate, need for fertility treatments, mode of delivery or uterine ruptures in subsequent pregnancies. High rates of gynecological symptoms including spotting (30-32%), dysmenorrhea (47-49%) and sexual dysfunction (FSFI score 23)-are reported in both groups. ConclusionThe study did not demonstrate the superiority of double-layer closure over single-layer closure in terms of reproductive outcomes after a first CS. This challenges the current recommendation favoring double-layer closure, and we propose that surgeons can choose their preferred technique. Furthermore, the high risk of gynecological symptoms after a CS should be discussed with patients.

The effect of uterine closure technique on cesarean scar niche development after multiple cesarean deliveries.

To use saline infusion sonohysterography (SIS) to evaluate the effect of uterine closure technique on niche formation after multiple cesarean deliveries (CDs). Patients with at least one prior CD were evaluated for niche via SIS. Subgroups of any number repeat CD (>1 prior), lower-order CD (<4 prior), and higher-order CD (≥4 prior) were analyzed, stratifying by hysterotomy closure technique at last cesarean preceding imaging; techniques included Technique A (endometrium-free double-layer closure) and Technique B (single- or double-layer routine endo-myometrial closure). Niche defects were quantified (depth, length, width, and residual myometrial thickness). The primary outcome was clinically significant niche, defined as depth >2 mm. Statistical analysis was performed using chi-square, ANOVA, t-test, Kruskal-Wallis, and multiple logistic regression, with p-values of <0.05 were statistically significant. A total of 172 post-cesarean SIS studies were reviewed: 105 after repeat CDs, 131 after lower-order CDs, and 41 after higher-order CDs. Technique A was associated with a shorter interval to imaging and more double-layer closures. Technique B was associated with more clinically significant niches across all subgroups, and these niches were significantly longer and deeper when present. Multiple logistic regression demonstrated a 5.6, 8.1, and 11-fold increased adjusted odds of clinically significant niche following Technique B closure in the repeat CD (p<0.01), lower-order CD (p<0.001), and higher-order CD (p=0.04) groups, respectively. While multiple CDs are known to increase risk for niche defects and their sequelae, hysterotomy closure technique may help to reduce niche development and severity.

Horizontal mattress uterine closure compared to single layered lock suture in cesarean section - A retrospective cohort study

ObjectiveThe objective of this study is to compare the outcomes of standard cesarean section uterine closure, single-layered running lock sutures, versus using primary horizontal mattress sutures (the K uterine closure technique). MethodThis study used a retrospective cohort chart review of patients undergoing elective primary and repeat cesarean section between January 2016 and August 2020 at a South Florida hospital. From 613 included patients, 176 received the K uterine closure technique completed by a triple board-certified physician. Remaining 437 patients received single-layered lock uterine closure completed by other physicians in the same hospital. Clinical, demographic, and post-operative outcomes were collected using patients’ operative, post-operative, and progress notes. ResultsUsing the data gathered, the experimental group demonstrated a greater difference between pre- and post-cesarean section hemoglobin (p < 0.027) and hematocrit (p < 0.014) compared to single-layered lock closure methods. There was a significantly lower estimated blood loss (p < 0.001), however, there was no significant difference in the average quantitative blood loss (p < 0.374). There was also a significant reduction in the length of total and postoperative hospital stay (p < 0.001), but the total operation time was significantly increased (p < 0.016). No significant difference was found in the percentage of patients using opioids as pain management during hospital stay (p < 0.431). There was no need for blood transfusion nor an increase in infectious morbidity using this method. ConclusionsUsing the K uterine closure technique for post-cesarean section uterine closure was a reasonable alternative for closure of hysterotomy. It led to decreased duration of hospital stay and no significant difference in quantitative blood loss. The greater difference in hemoglobin and hematocrit for the K uterine closure technique group could be explained due to the significantly greater total operation time. Although the single-layered running lock suture closure is what has been more historically performed by obstetricians for cesarean sections, this data supports the viability and efficacy of the K uterine closure technique as an equally safe, non-inferior alternative. The value of this technique for uterine closure can be confirmed with future prospective studies and potential research in reduction of uterine scar defects. SynopsisPrimary horizontal mattress closure at cesarean section provides a safe alternative to single-layered lock closure and may reduce blood loss, hospital stay, and opioid use.

Intra-operative Guidelines for the Prevention of Uterine Niche Formation in Cesarean Sections: A Review.

Formation of a uterine niche following a C-section can predispose the patient to future obstetric complications such as dehiscence, uterine rupture, ectopic pregnancy, and placenta accreta. The significant morbidity and mortality of these complications along with increasing C-section rates emphasizes the importance of prevention. However, there are no clear guidelines on intra-operative protocol to prevent postpartum niche formation. Besides surgical technique, the novel use of platelet-rich plasma (PRP) and mesenchymal stem cell (MSC) injections has demonstrated promising potential and may have applications in hysterotomy closures. The objective is to examine current research on optimal C-section procedures to prevent uterine niche formation and subsequent obstetric complications. A systematic review was conducted using PubMed and Google Scholar. Initial searches yielded 827 results. Inclusion criteria werehuman, animal, and in-vitro studies, peer-reviewed sources, and outcomes pertinent to the uterine niche. Exclusion criteria applied to articles with outcomes unrelated to myometriumand interventions outside of the intra-operative and immediate pre-/post-operative period. Based on the criteria, 41 articles were cited. Pathophysiology of uterine niche formation was associated with incisions through cervical tissue, adhesion formation, and poor approximation. Significant risk factors were low uterine incisions, advanced cervical dilatation, low station, non-closure of the peritoneum, and creation of a bladder flap. There was no consensus on uterine closure as it likely depends on surgical proficiency with the given technique, but a double-layered non-locking suture appears reliable to reduce niche severity. Recent trials indicate that intra-operative PRP/MSC injections may decrease niche incidence and severity, but more research is needed. If prevention or minimization of uterine niche is desired, the optimal C-section protocol shouldavoid low uterine incisions, choose uterine closure technique based on the surgeon's proficiency (double-layered non-locking is reliable), and close the peritoneum, and myometrial injection of PRP/MSC may be a useful adjunct intervention pending further clinical evidence.

Single Versus Double Layer Uterine Closure Technique According to Development of Uterine Niche: A Literature Review

Prevalence of cesarean deliveries increases globally. The prevalence of cesarean births increased from 5% in 1970 to 31.9% in 2016. There are short term and long-term complications of cesarean delivery including uterine niche. After a cesarean, the uterus is closed using a variety of methods, such as single- and double-layer closures with/without locking. This study compared single-layer and double-layer uterine closure with regard to the outcomes and complications. This review was synthesized and obtained from various online databases. Scientific articles were selected based on the inclusion criteria. The result showed that cesarean deliveries is a hysterotomy and an open abdominal incision (laparotomy) to deliver the fetus. An iatrogenic pouch-like defect known as a uterine niche result from improper tissue repair at the site of a prior cesarean scar. Up to 70% of women who have had a prior cesarean section experience uterine niche, of which 30% have symptoms. Compared to a single full-thickness closure, a single-layer, decidua sparing closure approach is more likely to result in an incomplete closure. No differences were discovered between the single- and double-layer closure techniques with locked first layers, but double-layer closures without locking resulted in thicker residual myometrium thickness when compared with locked single-layer closures. It is also possible that the locked suture can strangulate the scar tissue leading to poorer healing. Current evidence shows that no significant difference between single-layer and double-layer uterine closure techniques following in terms of uterine niche development.

Tek kat ve çift kat onarımın rezidüel miyometriyal kalınlık, istmosel oluşumu ve jinekolojik bozukluklar üzerine etkisi: Prospektif Randomize Kontrollü Bir Çalışma.

Abstract:&#x0D; Physicians are making great efforts to decrease the long-term complications of the cesarean section such as placental adherent syndromes, uterine scar pregnancies, uterine rupture, abnormal menstrual bleeding, or isthmocele. There is a controversy about the closure technique of the cesarean incision. The purpose of that study was to compare the impact of single layer versus double-layer closure of the hysterotomy incision on the residual myometrial thickness, isthmocele, menstrual disorders, dysmenorrhea, and dyspareunia.&#x0D; Material and Method&#x0D; A prospective randomized cohort study has been performed in a tertiary center named Bursa Yuksek İhtisas Training Research Hospital between July – October 2021. Patients were randomly assigned to each procedure (1:1) to the Single Layer Locked Continuous group and Double-layer Continuous un-locked group as uterine closure technique. Patients were examined via transvaginal ultrasound to evaluate the isthmocele occurrence, residual myometrium thickness, and inquired about menstrual properties, dysmenorrhea, and dyspareunia. Patients were also divided into groups via underwent first cesarean and more than one cesarean. &#x0D; Results:&#x0D; The numbers of the women whose hysterotomy incision was closed by single-layer locked continuous( SLLC) technique and double-layer un-locked continuous(DLUC) technique 68 and 71 respectively. There was no statistically significant difference in terms of demographic variables, obstetric history, post-operative complications, neonatal outcomes. The comparison of these groups revealed that there was no significant difference in terms of post-menstrual bleeding, heavy menstrual bleeding, post-coital bleeding, dysmenorrhea, dyspareunia. The incisional residual myometrial thickness was higher in the DLUC group with a p-value of 0,007. Six patients in SLLC and 5 patients in the DLUC group have detected isthmocele (p: 0,941). &#x0D; Patients have also been categorized as women who undergone their first cesarean section (SLLC n: 33 versus DLUC, n:33) and more than one cesarean section (SLLC n: 35 versus DLUC, n:38). Comparing the patients in these subgroups also did not differ significantly in terms of isthmocele occurrence, menstrual disorders, or residual myometrial thickness. &#x0D; Conclusion:&#x0D; No significant difference had occurred in terms of isthmocele incidence, or menstrual disorders comparing the single layer versus double-layer closure. However, women whose hysterotomy insicions were closed with double-layer un-locked continuous technique have a thicker resudial myometrium than single layer closure group especially women who underwent repeated cesarean.

Impact of purse-string uterine suture on scar healing after a cesarean delivery: a randomized controlled trial

Uterine closure technique can affect scar healing, potentially resulting in unfavorable gynecologic and life-threatening obstetrical outcomes. Double-layer continuous unlocked suture has been demonstrated to promote optimal residual myometrial thickness. Recently, the purse-string uterine suture technique has emerged as a viable method to enhance the healing of scars. However, the current lack of randomized trials assessing the relevance of this technique warrants further investigation. This study aimed to evaluate the impact of purse-string uterine sutures on scar healing after cesarean delivery when compared with double-layer continuous unlocked suture. This was a randomized controlled trial; 126 patients with singleton pregnancies undergoing primary cesarean delivery were enrolled in 2 groups. The primary outcome was the mean residual myometrial thickness measured by saline infusion sonography 6 months after surgery by 2 sonographers blinded to uterine closure techniques. Operative time, calculated blood loss, total number of needed threads, and perioperative scar width were used for the perioperative analysis. Healing ratio and cesarean scar defect measurements were used for the 6-month analysis. There was no significant difference in terms of residual myometrial thickness (9.38±2.3 vs 8.4±3.9 mm; P=.187), blood loss (540 [146-982] vs 495 [241-903] mL; P=.815), or operative time (6.2 [5.2-7] vs 6 [5.3-7] minutes; P=.977). Achievement of purse-string uterine suture required significantly fewer threads (1 [1-1] vs 2 [1-2]; P<.001) and fewer hemostatic complementary sutures (1 [1-1] vs 1 [1-2]; P=.013). Scar width was significantly lower with purse-string uterine sutures (50 [40.5-50.5] vs 70 [60-70.5] mm; P<.0001). Purse-string uterine sutures allowed a higher healing ratio (1 [0.9-1] vs 0.84 [0.59-1]; P=.003) and significantly fewer cesarean scar defects (12% vs 35%; P=.018) compared with double-layer continuous unlocked suture. Despite resulting in no difference in residual myometrial thickness, purse-string uterine closure seems to be associated with better uterine scar healing on the basis of a higher healing ratio, and a lower rate of cesarean scar defects compared with double-layer continuous unlocked suture.

The Impact of Uterine Incision Closure Technique on the Post Cesarean Residual Myometrial Thickness and Scar Defects. A Novel Technique at a Tertiary Care Hospital

The Impact of Uterine Incision Closure Technique on the Post Cesarean Residual Myometrial Thickness and Scar Defects. A Novel Technique at a Tertiary Care Hospital

Variations in uterine closure technique: an institutional survey of obstetricians and implications for patient counseling and prevention of adverse sequelae.

To assess the diversity of uterine closure techniques (UCTs) among providers in one institution and evaluate concurrent consideration of adverse outcomes for patient counseling, provisional care, and prevention. Forty-four obstetricians at NYU Langone Health were emailed a survey of their uterine closure technique, patient counseling, and practice experience. Results were stratified by years of practice:≤5, 5-20, and 20-40 years. Thirty-nine obstetricians (88.6%) completed the survey. Among those, a blunt uterine opening was preferred by 29 (74.4%), and a mid-lower segment location was favored by 34 (87.2%). At uterine closure, the endometrium was included by 20 (51.3%), with half a centimeter or more incorporated in the myometrial closure, whereas 15 (38.5%) did not factor in the endometrium's presence. Closure duration varied from 1 to 20min, with 21 (53.9%) lasting 1-5min and 12 (30.8%) lasting 5-10min. All physicians were familiar with the potential post-cesarean complications and counseled their patients accordingly; 25 (64.1%) at the first post-op visit while 14 (35.9%) did so before the next conception. Practitioners with fewer years in practice endorsed the safety of up to five consecutive cesarean births, while those with more experience approved up to ten. Thirty-two obstetricians (82.1%) stated that the risk of abnormal placentation is exclusively associated with the number of cesarean sections, whereas five (12.8%) senior obstetricians asserted that individual surgical techniques are most impactful. The survey illustrates that various UCTs are performed irrespective of potential adverse sequelae and without consideration for subsequent patient counseling and care. Ongoing research must study the impact of UCT on scar healing to formulate preventive strategies for post-cesarean complications.

Uterine incision closure: Is it the culprit in the cesarean scar niche and related complications?

Uterine closure technique is emerging as a significant factor in cesarean scar niche formation and its associated long-term complications. The authors recommend an endometrium-free closure technique and a high-volume surgeon for performing the procedure.

62 Single- Versus Double-Layer Uterine Closure After Cesarean Section Delivery: A Systematic Review and Meta-Analysis

Abstract Aim To compare single-layer (SL) with double-layer (DL) uterine closure techniques after caesarean section in terms of ultrasonographic findings and rate of CS complications. Method PubMed, Scopus, Web of Science, and Cochrane Library were searched for relevant randomized clinical trials (RCTs). Retrieved articles were screened, and relevant studies were included in a meta-analysis. Continuous data were pooled as mean difference (MD) with 95% confidence interval (CI), and dichotomous data were pooled as relative risk (RR) and 95% CI. Analysis was conducted using RevMan software (Version 5.4). Results Eighteen RCTs were included in our study. Pooled results favoured DL uterine closure in terms of residual myometrial thickness (MD = -1.15, 95% CI [-1.69, -0.60], P &amp;lt; 0.0001) and dysmenorrhea (RR = 1.36, 95% CI [1.02, 1.81], P = 0.04), while SL closure had shorter operation time than DL closure (MD = -2.25, 95% CI [-3.29, -1.21], P &amp;lt; 0.00001). Both techniques had similar results in terms of uterine dehiscence or rupture (RR = 1.88, 95% CI [0.63, 5.62], P = 0.26), healing ratio (MD = -5.00, 95% CI [-12.40, 2.39], P = 0.18), maternal infectious morbidity (RR = 0.94, 95% CI [0.66, 1.34], P = 0.72), hospital stay (MD = -0.12, 95% CI [-0.30, 0.06], P = 0.18), and readmission rate (RR = 0.95, 95% CI [0.64, 1.40], P = 0.78). Conclusions DL closure of caesarean uterine scar is associated with more residual myometrial thickness and less dysmenorrhea compared with SL uterine closure. But SL closure has the advantage of the shorter operation time.

The Impact of Uterine Incision Closure Techniques on Post-cesarean Delivery Niche Formation and Size: Sonohysterographic Examination of Nonpregnant Women.

To compare the prevalence and size of residual niche in the nongravid uterus following Cesarean delivery (CD) with different hysterotomy closure techniques (HCTs). Saline infusion sonohysterogram (SIS) was performed in women after one prior CD, documenting the presence or absence of a postoperative niche and measuring its depth, width, length, and residual myometrial thickness. Women were grouped by HCT: Technique A (endometrium-free) and Technique B (routine non-endometrium-free). The primary outcome was the prevalence of a clinically significant niche, defined as a depth of >2 mm. HCT groups were compared using χ2 , T-test (ANOVA), and analyzed using logistic regression and two-sided test (P < .05). Forty-five women had SIS performed, 25 and 20 via Technique A and B, respectively. Technique groups varied by average interval time from CD to SIS (13.6 versus 74.5 months, P=0.006) but were otherwise similar. Twenty niches were diagnosed, 85% of which were clinically significant, including five following Technique A, nine following Technique B with double-layer closure, and three following Technique B with single-layer (P=.018). The average niche depth was 2.4 mm and 4.9 mm among the two-layer subgroups following Techniques A and B, respectively (P=.005). A clinically significant niche development was six times higher with Technique B when compared to Technique A (OR 6.0, 95% CI 1.6-22.6, P=.008); this significance persisted after controlling for SIS interval on multivariate analysis (OR 4.4, 95% CI 1.1-18.3, P=.04). The average niche depth was 5.7 ± 2.9 mm following Technique B with single-layer. Hysterotomy closure techniques determine the prevalence of post-Cesarean delivery niche formation and size. Exclusion of the endometrium at uterine closure reduces the development of significant scar defects.

Single- Versus Double-Layer Uterine Closure After Cesarean Section Delivery: A Systematic Review and Meta-Analysis.

Cesarean section (CS) delivery is a common procedure, and its incidence is increasing globally. To compare single-layer (SL) with double-layer (DL) uterine closure techniques after cesarean section in terms of ultrasonographic findings and rate of CS complications. PubMed, Scopus, Web of Science, and Cochrane Library were searched for relevant randomized clinical trials (RCTs). Retrieved articles were screened, and relevant studies were included in a meta-analysis. Continuous data were pooled as mean difference (MD) with 95% confidence interval (CI), and dichotomous data were pooled as relative risk (RR) and 95% CI. Analysis was conducted using RevMan software (Version 5.4). Eighteen RCTs were included in our study. Pooled results favored DL uterine closure in terms of residual myometrial thickness (MD = -1.15; 95% CI -1.69, -0.60; P < 0.0001) and dysmenorrhea (RR = 1.36; 95% CI 1.02, 1.81; P = 0.04), while SL closure had shorter operation time than DL closure (MD = -2.25; 95% CI -3.29, -1.21; P < 0.00001). Both techniques had similar results in terms of uterine dehiscence or rupture (RR = 1.88; 95% CI 0.63, 5.62; P = 0.26), healing ratio (MD = -5.00; 95% CI -12.40, 2.39; P = 0.18), maternal infectious morbidity (RR = 0.94; 95% CI 0.66, 1.34; P = 0.72), hospital stay (MD = -0.12; 95% CI -0.30, 0.06; P = 0.18), and readmission rate (RR = 0.95; 95% CI 0.64, 1.40; P = 0.78). Double-layer uterine closure shows more residual myometrial thickness and lower incidence of dysmenorrhea than single-layer uterine closure of cesarean section scar. But single-layer closure has the advantage of the shorter operation time. Both methods have comparable blood loss amount, healing ratio, hospital stay duration, maternal infection risk, readmission rate, and uterine dehiscence or rupture risk.

Risk of uterine niche following single-layer locked versus unlocked uterine closure: a randomized study

Introduction The primary objective of the present study is to evaluate the effect of single-layer locked versus single-layer unlocked uterine closure techniques on the development of uterine niche. The secondary objective is to evaluate the effect of the ratio of lower uterine segment (LUS) to upper uterine segment (UUS) on the development of uterine niche, which was not previously investigated in literature but which the authors consider to be a major risk factor for the development of uterine niche. Methods Included in this randomized study were 194 patients who were admitted to the Department of Obstetrics and Gynecology at Health Sciences University Antalya Training and Research Hospital and who underwent cesarean section (CS) due to any reason between October 2017 and May 2018. Two different techniques were used in the closure of hysterotomy: Single-layer locked continuous suturing (Group 1) and single-layer unlocked continuous suturing (Group 2). During surgery, the thicknesses of the LUS and UUS were measured using a sterile scale prior to hysterotomy closure. The patients were evaluated for the development of uterine niche at postoperative six months by transvaginal ultrasound. Results Control transvaginal ultrasound performed at six months after surgery revealed uterine niches in 58 out of 194 patients (29.29%; 34 patients in Group 1 [34.3%] and 24 patients in Group 2 [25.3%]). No significant difference was noted in terms of the development of uterine niche between the two groups (p = .167). The mean LUS and UUS in patients without uterine niche development were 6.81 ± 1.26 mm and 9.38 ± 1.26 mm, whereas the mean LUS and UUS in patients with uterine niche development were 4.24 ± 1.15 mm and 9.21 ± 2.15, respectively (p = .001 and p = .236). The mean UUS/LUS ratio is 1.4 ± 0.16 among patients without uterine niche and 2.21 ± 0.31 in patients with uterine niche (p < .001). Conclusions The present study found no statistically significant difference in niche size between the two groups. However, the study reports that the ratio of upper to lower uterine segment that was not previously investigated in literature is a major risk factor for the development of uterine niche.

Online survey on uterotomy closure techniques in caesarean section.

Uterine closure technique in caesarean section (CS) influences the rate of late complications in subsequent pregnancies. As no common recommendation on suture techniques exists, we developed a questionnaire to determine the techniques currently used and the frequencies of late complications. The online questionnaire consisted of 13 questions and was sent to 648 obstetric hospitals (level I-IV) in Germany. Number of CS, rate of vaginal birth after caesarean section (VBAC), the type of uterus suturing technique and the frequency of uterine dehiscences, ruptures and placenta accreta spectrum (PAS) were queried. The answers were anonymous, and results were evaluated descriptively. The response rate was 24.7%. The mean CS rate was 27.3% (±6.2), the repeat CS rate 33.2% (±18.1). After CS, 46.2% (±20.2) women delivered vaginally. To close the uterotomy, 74.4% of hospitals used single layer continuous sutures, 16.3% single layer locked sutures, 3.8% interrupted sutures, 3.1% double layer continuous sutures and 2.5% used other suture techniques. The percentages of observed uterine dehiscences did not differ significantly between the different levels of care nor did the uterotomy suture techniques. There is no uniform suturing technique in Germany. A detailed description of suture technique in surgery reports is required to evaluate complications insubsequent pregnancies. National online surveys on obstetric topics are feasible and facilitate the discussion on the need to define a standardized uterine closure technique for CS.

Cost-effectiveness of single-layer versus double-layer uterine closure during caesarean section on postmenstrual spotting: economic evaluation alongside a randomised controlled trial

ObjectiveTo evaluate the cost-effectiveness of double-layer compared with single-layer uterine closure after a first caesarean section (CS) from a societal and healthcare perspective.DesignEconomic evaluation alongside a multicentre, double-blind, randomised controlled...

A new technique for uterine incision closure at the time of cesarean section: does it make a difference?

The purpose of this study was to compare the short-term operative outcomes of three different surgical techniques for uterine incision closure during caesarean section (CS). This trial enrolled 120 patients scheduled for primary caesarean delivery. Patients were randomised into either classical double-layer uterine closure, purse-string double-layer uterine closure (Turan), or our new approach of uterine closure (double layer step up-step down technique). For short-term comparison, transvaginal ultrasonography was planned for all patients 6 weeks after surgery. Compared to group II and Group III, residual myometrial thickness was significantly thinner in group I (p < .001). The number of patients with uterine niche was 10 (50% of all scar defects) in group I whereas it was 4 (20%) in group II and 6 (30%) in group III. Operative time was significantly longer in group II (p < .001). This led to our conclusion that Turan technique and our new approach are associated with thicker myometrial thickness and less frequency of uterine scar defect than classical double-layer uterine incision closure; however, our approach takes less operative time. Clinical Trial Registration: ClinicalTrials.gov Identifier: NCT04681378 Impact statement What is already known on this subject? Many variations in CS technique have been studied. For example, single-layer uterine incision closure has been compared to double-layer uterine incision closure. Purse string double layer (Turan) has been also compared to the traditional double-layer technique. Double layer unlocked closure has been shown to result in a thicker residual myometrium and as a consequence can possibly lead to the decrease of niche development after a CS compared to single-layer closure with lower frequency of uterine scar defect with Turan technique. What do the results of this study add? Here we introduce a new uterine closure technique, which we have named double-layer step up–step down technique, as an alternative method. With this technique, the uterine incision contract more than with the traditional double layer technique and has similar results to the Turan technique; however, our approach takes less operative time. What are the implications of these findings for clinical practice and/or further research? These alternative techniques of uterine incision closure decrease the frequency of uterine niche that may be associated with many clinical problems such as ectopic pregnancy at the CS scar, placenta accreta, rupture of the uterus during a subsequent pregnancy. Future studies are needed to investigate the frequency of uterine rupture in a subsequent pregnancy following different uterine incision closure techniques.

Babu and Magon uterine closure technique during cesarean section: A randomized double-blind trial.

We compared the effectiveness of the Babu and Magon uterine closure technique and unlocked double-layer uterine closure on the integrity and thickness of the uterine scar. A randomized double-blind trial was performed at Hazrat-e Rasoul -e-Akram Hospital, Tehran, Iran, from March 2018 to December 2019, in 72 pregnant women who were candidates for cesarean section for the first time. Women were randomly assigned to the Babu and Magon uterine closure technique (intervention group, n=34) or double-layer closure of the uterine incision (control group, n=38). The primary outcome of the study was the frequency of myometrial defects at the site of the scar (niche), and a large niche. Secondary outcomes, including the time taken for uterine closure and postpartum hemorrhage (early and late), were compared between groups. Adjacent myometrium thickness (AMT) between the two groups was not statistically significant. A niche was reported in 23.5% (8/34) and 50% (19/38) of women in the intervention and controls, respectively (p=0.02). A large niche was reported in 2.9% (1/34) and 23.7% (9/38) of women in the intervention and controls, respectively (p < 0.01). The duration of uterine closure was not statistically significant between the two groups. Hemoglobin levels did not differ significantly between groups during the first 24 h post-surgery. The results of the study showed that the technique of uterine closure is one of the main potential determinants of myometrial healing. The Babu and Magon uterine closure technique seems to lead to tissue alignment during suturing and consequently cause better myometrial healing, although this issue calls for well-founded longer studies of appropriate design.