The Never Ending Debate SingleLayer Versus Double

Authors: C V Hegde

Publish Date: 2014/07/23

Volume: 64, Issue: 4, Pages: 239-240

PDF Link

Abstract

In the beginning—a caveat This short review article will not discuss all aspects of cesarean sections but will be finely nuanced and limit itself to the merits/demerits of a singlelayer closure of the uterine incision versus a doublelayer closure Therefore references have been chosen which are relevant recent and which bring some value addition to the discussion This is also not the place to discuss any particular “new” method of uterine incision closure unless it has been exhaustively practiced and reviewed after its introductionAll through the twentieth century barring exceptions the uterus was probably sutured in two layers at cesarean section The sutures were chromic catgut and as described in Munro Kerr the first layer was probably a continuous locking one and the second layer was continuous and meant to “bury” the first A few hardy souls I suspect must have dared even then to suture the uterus in one layer with chromic catgutNow that suturing is done with delayed synthetic absorbable material like polyglactin which has among its properties a greater tensile strength for a longer period of time and delayed degradation as compared to chromic catgut suturing the uterine incision at cesarean section in a single layer seems empirically to have more takers Then there are those who have traditionally sutured the uterus at cesarean section in two layers and are loathe to change a practice which has stood them in good steadThe questions raised by any method departing from a set template include those of safety efficacy and complications both immediate and delayed The proponents of the singlelayer closure with polyglactin often cite advantages of this method being efficient quick safe less cumbersome and reduced bleeding as compared to the twolayered closure It would stand to reason that whatever the methodology of closure the twin objectives that must be met are safe hemostasis and an insurance against rupture uterus in a future trial of laborIn a multicenter case control study 1 where the objective was “to evaluate the effects of prior singlelayer compared with doublelayer closure on the risk of uterine rupture” the cases chosen were those who had a previous single transverse lower segment incision and had a complete rupture of the uterus during a trial of labor The controls 288 were three times the cases 96 and comprised women who had a prior low transverse uterine incision and underwent trial of labor without rupture Multiple variables included risk factors such as “prior uterine closure suture material diabetes prior vaginal delivery labor induction cervical ripening birth weight prostaglandin use maternal age gestational age and interdelivery interval” The rate of singlelayer closure was 36  35 of 96 in the case group and 20  58 of 288 in the control group P  001 Singlelayer closure was related to uterine rupture associated with adverse neonatal outcome odds ratio OR 289 95  confidence interval CI 101–827 Singlelayer closure OR 269 95  CI 137–528 and birth weight greater than 3500 g OR 203 95  CI 121–338 were also linked with increased rates of uterine rupture The authors concluded that “a prior single layer closure carries more than twice the risk of uterine rupture compared with a double layer closure and that singlelayer closure should be avoided in women who could contemplate future vaginal birth after cesarean delivery” The study had a level II evidenceA review article in the International Journal of Gynecology and Obstetrics 2 evaluated “the best available evidence regarding the association between singlelayer closure and uterine rupture” The methodology included a Medline Embase and Cochrane database search for “relevant observational and experimental studies that included women with a previous single low transverse cesarean delivery who had attempted a trial of labor TOL” 5810 women were reviewed in nine studies and “a sensitivity analysis indicated that the risk of uterine rupture was increased after a locked singlelayer closure OR 496 95  CI 258–952 P  0001 but not after an unlocked singlelayer closure OR 049 95  CI 021–116 compared with a doublelayer closure” The study concludes that a locked single layer rather than unlocked single layer was associated with a higher risk of rupture than a double layer in women after trial of laborA detailed Cochrane database review 3 reviewed several variables including uterine closure at cesarean section The search method included the Cochrane Pregnancy and Childbirth Group’s Trials Register Nov 2007 This search was updated on May 31 2012 The selection criteria included “all published unpublished and ongoing randomised control led trials comparing various types and closure of uterine incisions during Cesarean section” The authors came to the conclusion that there was no information regarding either the optimal suture material or a suturing technique for the uterine incision In an article 4 “subjects with one previous cesarean section by documented transverse uterine incision that attempted VBAC were identified Uterine rupture and VBAC success rates were compared between those with singlelayer and doublelayer uterine closure Of 948 subjects identified 913 had doublelayer closure and 35 had singlelayer closure The uterine rupture rate was significantly higher in the singlelayer closure group 86 vs 13  P = 0015” In another study where the merits and demerits of a singlelayer closure of the uterine incision in a continuous and continuous locked manner were compared by Hudic et al 5 and there was no significant difference in uterine scar disruption between the two groups This was by means of a retrospective cohort study in a population where unlocked and locked sutures were used This study further nuances a singlelayer closure method but contradicts a finding in a study mentioned earlier in this article The authors recommend a randomized trial to be performedA study of these reviews may suggest a bias against the singlelayer closure with a greater chance of rupture in a future trial of labor however such a conclusion may be simplistic due to the fact that there is at present no conclusive evidence to prove that a doublelayer closure would not result in rupture in a similar situation The variables that exist in each case including previous vaginal delivery birth weight the integrity of the previous scar a preexisting medical condition and others make it well nigh impossible to dictate any superior methodology to suture a uterine incision at cesarean section The debate rages on However suturing a thick muscular organ would at times necessitate a doublelayer closure if at all only for achieving hemostasis Flexibility of approach I suppose is the one rule we may rigidly follow

Keywords: