Trial of Labor After One-Layer Cesarean Closure

ABSTRACT & COMMENTARY

Synopsis: The type of low transverse cesarean closure does not significantly affect maternal or perinatal outcome in a subsequent pregnancy.

Source: Chapman SJ, et al. Obstet Gynecol 1997;89:16-18.

To determine pregnancy outcome after a one-layer closure of a low transverse cesarean incision, Chapman et al reviewed the results of trials of labor in 164 subsequent deliveries of women who had been randomly assigned in a previous pregnancy to either a single layer or two-layer repair. Nineteen study subjects (12%) were delivered by elective repeat cesarean section without labor. Of the remaining 145 women, 70 had undergone a one-layer closure and 75 a two-layer closure. Length of labor, method of delivery, duration of hospital stay, gestational age at delivery, and, most importantly, uterine scar dehiscence and uterine rupture did not differ significantly between the groups. Of note, 56% of the women in the one-layer closure group, and 64% in the two-layer closure group had successful trials of labor. More than half of the study subjects received oxytocin. No differences were noted in neonatal outcome. One patient in the previous one-layer closure group did have a uterine scar dehiscence and was delivered by cesarean section for a nonreassuring heart rate tracing. Her infant did well.

The authors conclude that the type of low transverse cesarean closure does not significantly affect maternal or perinatal outcome in a subsequent pregnancy.

COMMENT BY STEVEN G. GABBE, MD

Over the past five years, increasing evidence has accumulated that a continuous, single-layer closure of a low transverse cesarean delivery incision has several advantages, including a shorter operative time and the requirement for fewer hemostatic sutures. It has been suggested that the second layer of a two-layer closure does not strengthen the incision and, in fact, may weaken it by causing more tissue devascularization. In a previous report, Hauth et al randomly assigned 906 women to a one- or two-layer closure using 1-0 chromic gut in a continuous locking technique (Am J Obstet Gynecol 1992;167:1108-1111). The study subjects in the present report were recruited from that earlier study, thus providing a group of patients who had been randomly assigned to one technique or the other. It is reassuring to see that in a subsequent pregnancy, women who had a one-layer closure did just as well as those who had the more time-consuming two-layer procedure. As the authors point out, their study did not have the statistical power necessary to determine whether uterine dehiscence or uterine rupture, both uncommon events, differed in the two groups.