Caesareans - something important to ask...

[BellyBelly]

I've added this into the birth preferences / birth plan template I give to the women I support and on BB... asking to be sure to have a double layer closure. There has been lots of talk of this lately about single layers effecting the chances of a successful VBAC and being more likely to rupture. Will try and find out more.

One- vs. two-layer closure of uterus

One-layer closure of the uterus at CS has been suggested as a means of decreasing operating time with no associated or subsequent increase in morbidity. Current practice in the UK reports that 96% of surgeons use a double layer closure and 3% a single layer.306 [evidence level 3]

A systematic review compares single versus two-layer suturing for closing the uterine incision at CS.429 [evidence level 1a] Two RCTs were included in the review (n = 1006). These RCTs measured different outcomes. One RCT (n = 906) analysed operating time and number of haemostatic sutures.430 [evidence level 1b] The results showed a shorter mean operating time of 5.6 minutes (43.8 versus 47.5 minutes, p = 0.0003) and fewer haemostatic sutures in the one layer closure group.

In the second RCT all the women had hysterography to determine integrity of the uterine scar 3 months after the CS in the first half of the menstrual cycle.431 [evidence level 1b] In the control group (two-layer closure) 82% of cases had either a major or minor scar deformity and in the intervention group (one layer closure) scar deformity was lower (26%). The method of randomisation in this RCT is unclear and the clinical significance of the hysterography findings as an outcome measure is uncertain.

The two RCTs have been published after the systematic review. Both assessed operating time as an outcome measure. One RCT (n = 188) found no difference in operating time432 [evidence level 1b] and the other RCT (n = 200) found a decrease in operating time with single layer closure of the uterus, the absolute difference was 12 minutes.433 [evidence level 1b]

These four RCTs used slightly different methods of single layer closure, two RCTs describing the use of continuous unlocked suture of the uterus, one RCT used continuous locked sutures while another RCT used interrupted sutures. The two later RCTs both used vicryl suture material, one of the earlier RCTs used chromic catgut and one RCT did not describe what suture material was used. None of the RCTs directly compared locked versus unlocked sutures.

Concern about the use of single layer closure of the uterus and scar rupture in future pregnancies have been raised by a cohort study (n = 2142) that reported an increase likelihood of uterine rupture in women who had had a single layer closure of the uterus (OR 3.95, 95% CI 1.35 to 11.49).434 [evidence level 2b] Follow up of the women recruited in one of these RCTs has also been reported.435 Of 164 subsequent births, 19 women had elective repeat CS and 145 experienced labour. Length of labour, mode of birth, incidence of uterine scar dehiscence and other labour outcomes were not significantly different between those women who had had previous one or two layer closure.435 [evidence level 2a] Closure of the uterus is currently being studied in a large UK RCT (CAESAR).436

RECOMMENDATION

The effectiveness and safety of single layer closure of the uterine incision is uncertain.
Except within a research context the uterine incision should be sutured with two
layers.

[{sarah}]

Hey Kelly, how would you go about finding out what they did? Would the hospital have those records? There's nothing on my discharge paperwork that says anything about closure.

[*Rae*]

Ditto what Sarah said - i can't find anything that tells me what kind of incision i have or even the position of it.

[BellyBelly]

It should be in your hospital notes. Apparently a midwife had a discussion with some doctors and Obs who laughed and said that it wouldn't happen here in Australia and was not a problem, but on going through some patients notes, she clearly saw that they had done a single layer. It's a good idea to add the request to your birth preferences so you can make it clear that you definitely want double layer...

[anney]

Sarah,
the ob or surgeon that did your op. will have written an operation report which should list the information you want. You could write to the hospital and ask either for the copy of the operation report or just ask the specific question on whether you had a double or single layer closure. Alternatively you could get your GP to write as sometimes hospitals are reluctant to give patients medical information in case it is misunderstood.

[{sarah}]

Ok cool, I shall see what I can find out...

[*Rae*]

Thanks for the advice girls Will also look into it.

[christy]

My OB told me the morning after my c/s that he did a dual layer and that meant I had a higher chance at VBAC. I'm not sure why he mentioned it but maybe because we were discussing dog c/s during recovery & how we stitch them up at work.

[mummato3]

I received a copy of my cs hospital notes frm 1998 and its doesnt say anything about whether it was a single or dual layer of stitching. I am thinking of prehaps contacting the ob's rooms and asking the midwife there.