Over 1.2 million mothers in the United States deliver their babies by cesarean section every year. According to the CDC, that’s roughly 31.9 percent of all deliveries performed in the country, making it the most common surgery performed nationwide.
C-sections are performed for a number of reasons, but generally they happen when a complication arises during labor that makes a traditional vaginal birth difficult. This could be when the baby is positioned to come out feet first (otherwise known as a breech birth) or shoulder first (a transverse labor). They are also performed when the mother’s or baby’s life is at risk, such as when problems occur with the umbilical cord, the placenta, or the oxygen supply to the baby. Some C-sections are planned, but many are emergency procedures.
The surgery itself involves a laparotomy (an open abdominal incision) and a hysterotomy (an incision into the uterus) to remove the baby.
Then, once the baby is delivered, the doctor closes the uterine incision with one or two layers of sutures.
What’s the difference between a single and double layer of sutures?
These are two different methods of closing the incision in the uterus.
One is a single layer of sutures that pulls the edges of the incision together. This technique is particularly popular in Europe.
These are two different methods of closing the incision in the uterus.
Double sutures involve two layers of sutures: one that pulls the edges of the incision together and a second layer that imbricates (or pulls uncut tissue together over) the first layer. This method, says Dr. Daniel Roshan, a high-risk, maternal-fetal OB-GYN in New York City, “provides strength to the c-section scar.”
Why would my doctor use double sutures?
A number of studies suggest that patients who have a two-layer closure have less chance of uterine scar rupture with subsequent pregnancies and a better chance of being able to deliver vaginally after a C-section.
For example, one study published in 2002 involving 489 women with single-layer closures and 1,491 women with double-layer closures found that, when controlled statistically for the possible effects of other variables (such as Pitocin or epidural use), the uterine rupture rate with single-layer closure was 3.1 percent, compared to 0.5 percent with double layers.
So why would my doctor ever use a single layer of sutures?
The suture debate on single vs. double layers isn’t really settled within the medical community.
Some studies, such as this one, did not find a higher rate of uterine rupture with single-layer closure. Others found that an increased rate of rupture had less to do with one or two layers of sutures and more to do with whether the surgeon locked the stitch, i.e., after each stitch, passed the needle through the loop of the previous stitch.
For example, this 2011 study found that locked, but not unlocked, single-layer closures had a higher risk of uterine rupture. And another study found that a double-layer closure with a locked first layer didn’t have much difference in rupture rate compared to a locked single-layer closure.
A number of studies suggest that patients who have a two-layer closure have less chance of uterine scar rupture with subsequent pregnancies.
But even the research on locked vs. unlocked stitches isn’t clear-cut, because one 2008 review found no real difference between the two when it came to uterine rupture.
However, a single suture layer is faster to do by two to three minutes, says Dr. Roshan, which means that if general anesthesia is used for a C-section, the doctor might choose to use a single layer so that the mother is under anesthesia for a shorter period of time.
Because it takes less time, a single layer might also be used “if time is of the essence,” explains Dr. James Betoni, a California high-risk, maternal-fetal OB-GYN, or if the mother is getting her tubes tied at the same time, since the surgeon might need those extra minutes that a double suture would take to perform the procedure instead.
A single layer also causes less bleeding. Roshan also says that “there are times that the lower uterine segment is so thin that it seems the risk of uterine bleeding will increase if a two-layer closure is attempted.” In addition, some studies, like this one, suggest that a single-layer closure results in decreased risk of endometritis, an inflammation of the inner lining of the uterus.
If I have a single suture layer, does it mean I can’t attempt a vaginal birth after cesarean (VBAC)?
Even though a number of studies show an increased risk of uterine rupture with a single closure, “the difference is not so [great] to not try for vaginal delivery,” says Roshan.
Both Roshan and Betoni agree that there are other factors that play a much bigger role in determining whether it is safe for a mother to try to labor after a cesarean, including the reason for the surgery the first time.
Pre-pregnancy weight, weight gain during the pregnancy, the estimated fetal weight and the baby’s position, and the mother’s pelvis type and size are all factors that your doctor will weigh when considering whether it is safe to attempt a VBAC.
If you want to attempt a vaginal birth, it’s best to discuss this with your doctor ahead of time.
Can I tell whether my doctor used single or double sutures?
No. These are sutures on your uterus, not your skin, so there is no way to know unless you ask your doctor or read the surgeon’s operative report.
Can I request a certain type of closure?
Yes, of course.
But you should know that your doctor may need to make a change depending on how your C-section surgery goes. They may need to change course for your own safety.
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