REVIEW ARTICLE Single- versus double-layer closure of the hysterotomy incision during cesarean delivery and risk of uterine rupture Stéphanie Roberge a, b , Nils Chaillet c , Amélie Boutin a, b , Lynne Moore b, d , Nicole Jastrow e , Normand Brassard a , Robert J. Gauthier c , Igor Hudic f , Thomas D. Shipp g , Charlotte H.E. Weimar h , Zlatan Fatusic f , Suzanne Demers a , Emmanuel Bujold a, b, ⁎ a Department of Obstetrics and Gynecology, Faculty of Medicine, Université Laval, Quebec, Canada b Department of Social and Preventive Medicine, Faculty of Medicine, Université Laval, Quebec, Canada c Department of Obstetrics and Gynecology, Faculty of Medicine, Université de Montréal, Montreal, Canada d Centre Hospitalier Affilié Universitaire de Québec, Hôpital Enfant-Jésus, Quebec, Canada e Department of Obstetrics and Gynecology, Faculty of Medicine, Hôpitaux Universitaire de Genève, Université de Genève, Geneva, Switzerland f Clinic of Gynecology and Obstetrics, University Clinical Center, Tuzla, Bosnia and Herzegovina g Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School, Boston, USA h Department of Obstetrics and Gynecology, University Medical Centre Utrecht, Utrecht, The Netherlands abstract article info Article history: Received 23 December 2010 Received in revised form 17 April 2011 Accepted 27 June 2011 Keywords: Cesarean delivery Hysterotomy Pregnancy Uterine rupture Vaginal birth after cesarean Objective: To evaluate the best available evidence regarding the association between single-layer closure and uterine rupture. Methods: The PubMed, Embase, and Cochrane Central Register of Controlled Trials databases were searched for relevant observational and experimental studies that included women with a previous single, low, transverse cesarean delivery who had attempted a trial of labor (TOL). The risks of uterine rupture and uterine dehiscence were assessed by pooled odds ratios (OR) calculated with a random effects model. Results: Nine studies including 5810 women were reviewed. Overall, the risk of uterine rupture during TOL after a single-layer closure was not significantly different from that after a double-layer closure (OR 1.71; 95% confidence interval [CI] 0.66–4.44). However, a sensitivity analysis indicated that the risk of uterine rupture was increased after a locked single-layer closure (OR 4.96; 95% CI 2.58–9.52, P b 0.001) but not after an unlocked single-layer closure (OR 0.49; 95% CI 0.21–1.16), compared with a double-layer closure. Conclusion: Locked but not unlocked single-layer closures were associated with a higher uterine rupture risk than double- layer closure in women attempting a TOL. © 2011 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. 1. Introduction Cesarean delivery is one of the most frequent surgical procedures performed worldwide, but for some technical aspects of this procedure a standard or consensus is still lacking [1,2]. Closure of the hysterotomy site is an aspect that has gained interest because of the potential relationship with uterine rupture during a trial of labor (TOL) in future pregnancies [3]. Uterine rupture, one of the worst obstetrical complications, is associated with significant neonatal and maternal morbidity [4,5]. Several techniques for myometrium closure have been described, including the use of interrupted, locked, and unlocked continuous sutures with single- or double-layer closure [1,6]. Single-layer locked, continuous suturing, popularized in North America during the late 1980s, is part of the Misgav–Ladach technique developed by Stark and colleagues [7,8]. Single-layer as opposed to double-layer closure has been shown to reduce operating time and blood loss [3]. However, a very large randomized controlled trial (RCT) [9] did not find such benefits, and long-term follow-up of these patients is currently lacking. Recent data indicate that single-layer closure may be one of the most important factors related to uterine rupture [10,11]. Therefore, a systematic review and a meta-analysis were performed to compare the impact of single- versus double-layer closure on uterine rupture risk. 2. Methods Medical subject headings and text words served to generate the key words “uterus”, “uterine”, “dehiscence”, “rupture”, “separation”, “scar”, “VBAC”, “vaginal birth after cesarean”, “closure”, “caesarean”, and “cesarean”. These key words were combined to search the electronic databases PubMed, Embase, and Cochrane Central Register International Journal of Gynecology and Obstetrics 115 (2011) 5–10 ⁎ Corresponding author at: Maternal-Fetal Medicine, Department of Obstetrics and Gynecology and Department of Social and Preventive Medicine, Faculty of Medicine, Université Laval, 2705, boulevard Laurier, Quebec, QC, Canada G1V 4G2. Tel.: + 1 418 933 6872; fax: +1 418 577 2024. E-mail address: emmanuel.bujold@crchul.ulaval.ca (E. Bujold). 0020-7292/$ – see front matter © 2011 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2011.04.013 Contents lists available at ScienceDirect International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo