Double-Layer Cesarean Closures May be Safer Uterine rupture more likely with one-layer closure;
Ob.Gyn.News, Mar 15, 2002, Vol 37, No 6;  

Single-layer closure after low transverse cesarean sections may leave women 5 times more susceptible to uterine rupture in a subsequent trial of labor compared with double-layer closure. 

Obstetricians moved away from two-layer closures after C-section because one-layer closures seemed sufficient and shortened operative time. The alarming study results should prompt further investigation of the safety of their approach….  

Three percent of the 398 women (12) who had a one-layer closure after C-section developed symptomatic uterine rupture during trial of labor, compared to 0.6% (3) of the 1,251 women whose C-sections were closed with two layers of sutures.(5B)  

Photos and graphics on the technical aspects of
double layer closure of the uterine surgical wound.

From these pictures, it is obvious why suturing in two layers would be significantly more effective at promoting good healing and protecting against uterine rupture in a future pregnancy.

Trying to close the 1 inch thick edges of the surgical incision into the uterus with a single line of sutures would be far less effective. The surgeon's "bite" down with the curved needle would not be able to go completely thru the muscular body of the uterus with each stitch, thus making the repair uneven. It may be gaps that will up with blood and interfere with good bonding of the two side of the tissue. This would be more vulnerable to rupture. 


(1a) Half way thru suturing the first layer, the surgeon secures the right angle (of the incision) with a separate,
 full  length suture, making sure that apposition and hemostasis are well accomplished. Then the original suture (b)
is continued until it meets up at the left corner ( where the suture for the second layer is waiting).


(2a) the second layer is sutured from the right angle to the left in a continuous fashion.
The edges of the uterovesical peritoneal fold are sutured in the following step 

(3) after the uterus is closed, the parital peritoneum is closed with 2/0 Vicryl suture on an atraumatic needle


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