The increasing prevalence of cesarean deliveries has raised concerns about long-term complications, including niche formation in the uterine scar. Niche development is associated with various gynecologic issues and obstetric complications in subsequent pregnancies. Despite its importance, there's uncertainty regarding the optimal uterine closure technique.
Niche formation, or defects in the uterine scar, can lead to gynecologic complaints and complications in future pregnancies. The debate over single-layer vs. double-layer uterine closure techniques persists, with conflicting evidence on which approach is superior for preventing long-term complications.

This study was published in the Journal Of Obstretrics & Gynaecology by Carry Verberkt and colleagues. A multicenter, double-blind, randomized controlled trial conducted in the Netherlands aimed to assess the impact of single-layer vs. double-layer closure of the uterine incision on long-term outcomes in women undergoing their first cesarean delivery. The primary outcome was live birth rate at a 3-year follow-up, with secondary outcomes including fertility, gynecologic, and obstetrical outcomes.
Key Findings:
• The study included 2292 women, with 830 in the single-layer closure group and 818 in the double-layer closure group.
• At the 3-year follow-up, there were no significant differences in live birth rates between the two closure techniques.
• Secondary outcomes, including pregnancy rate, need for fertility treatments, mode of delivery, and obstetrical complications, also showed no significant differences between the groups.

• Both groups reported high rates of gynecologic symptoms, including spotting, dysmenorrhea, and sexual dysfunction.
The study did not find superiority of double-layer closure over single-layer closure in terms of reproductive outcomes after a first cesarean delivery. This challenges the current recommendation favoring double-layer closure, suggesting that surgeons can choose their preferred technique. Additionally, the high prevalence of gynecologic symptoms after cesarean delivery highlights the importance of discussing these risks with patients.
Surgeons should consider individual patient factors and preferences when choosing uterine closure techniques during cesarean deliveries. Patient counseling regarding the potential for gynecologic symptoms post-delivery is crucial for informed decision-making. Further research may be needed to elucidate the long-term effects of different closure methods on maternal health and reproductive outcomes.
Reference:
Verberkt, C., Stegwee, S. I., Van der Voet, L. F., Van Baal, W. M., Kapiteijn, K., Geomini, P. M. A. J., Van Eekelen, R., de Groot, C. J. M., de Leeuw, R. A., Huirne, J. A. F., van Baal, M., Klerkx, W., Bekker, M. N., de Boer, K., Boormans, E. M. A., van Eijndhoven, H. W. F., Feitsma, H., Hehenkamp, W. J. K., Hemelaar, M., … de Vleeschouwer, M. Single-layer vs double-layer uterine closure during cesarean delivery: 3-year follow-up of a randomized controlled trial (2Close study). American Journal of Obstetrics and Gynecology,2023. https://doi.org/10.1016/j.ajog.2023.12.032