How do we close the uterus in a cesarean section? an online survey trial

Authors

Abstract

Aim: The uterine closure technique in cesarean section (CS) has a significant impact on healing and niche formation; however, there is still no consensus on the optimal method. We aimed to investigate the frequency of techniques used and the factors affecting them.
Materials and Methods: An anonymous online survey in Turkish with 12 questions was sent to available obstetricians in Turkey. The primary response of interest was the type of uterine closure technique favoured in CS. Secondary reactions of interest encompassed the formation of a bladder flap, closure of the peritoneum, rectus abdominis muscles, and subcutaneous tissues. The findings were also categorised based on the number of years of practice and affiliations. Results: 466 physicians filled out the survey. The primary approach utilised was the locked single layer at 75%, whilst the least preferred technique was the locked double layer at 6%. Also, 55.7% of physicians construct a bladder flap, whereas 80.8% routinely close the parietal peritoneum. 86% of surgeons typically choose to suture subcutaneous tissues when the thickness exceeds 2 cm. No significant difference was found in the frequency of uterine closure techniques between senior specialist physicians and less experienced obstetricians. Also, the most favourite technique was the locked layer in all affiliations.
Discussion: We showed that the predominant strategy for uterine closure in cesarean sections is the locked single-layer method. Moreover, most doctors seal the parietal peritoneum and stitch the subcutaneous tissue if it is thick.

Keywords

Introduction

Caesarean section (CS) is the most common operation among women, and the rate has risen substantially around the world in the last two decades [1]. This growing CS incidence has sparked attention in the possible short and long-term morbidity of cesarean scars. In almost 50% of women with a history of cesarean section, a uterine scar defect, referred to as a “niche”, characterized by disruption of the myometrium at the cesarean scar, can be observed [2]. Uterine scar defects detected on ultrasound several weeks or months after CS are associated with numerous gynecologic complications such as prolonged menstrual bleeding, intermenstrual spotting, and subfertility [3]. In addition to these gynecologic concerns, complications in subsequent pregnancies related to a niche were also reported, such as uterine rupture and placenta accreta spectrum (PAS) disorders [4]. In the present, these obstetric complications are among the most important causes of maternal morbidity and mortality, and they cause a severe social and economic burden. The exact mechanism for niche development remains unknown. Nonetheless, several studies have identified various prognostic risk factors for incomplete scar healing, including patient, labour, and surgery-related factors [5]. The impact of uterine closure technique on the stability of the uterine scar and the risk of developing a niche has become the focus of studies in recent years [6]. Studies that compare the impact of suture techniques on scar stability produce inconsistent outcomes. Some studies conclude that double-layer closure results in a thicker uterine scar, while others have found no significant difference between surgical techniques. Unfortunately, it is difficult to reach a definitive conclusion on this issue, and many international and national organizations fail to provide clear and explicit recommendations.
CS rates are increasing rapidly in our country, as is the case worldwide. In 2017, Turkey had a CS rate of 53.1%, which was nearly double the OECD average, and was the highest- ranked OECD country [7]. Regrettably, our nation ranks among the top five countries globally with the highest rates of CS, which remains a significant public health issue [8]. Although thousands of CS procedures are performed each day across our country, clinicians’ surgical techniques differ significantly. There is no data on maternal complications or the long-term effects of these surgical technique variations.
In this survey study, we aimed to determine the frequency of uterine closure techniques and the most commonly used methods by obstetricians and gynecologists during CS in our country, as well as other steps in the CS procedure.

Materials and Methods

An online survey (Jotform.com) was conducted among members of the Turkish Gynaecology and Obstetrics Association (TJOD). Survey questions were distributed to all participants via their social media accounts. The survey lasted two months (May to July 2025). After four weeks from the initial contact, all participants received an updated email request reminder. Consent to publish data was obtained from all respondents, and all responses were anonymous.
A survey in Turkish with 12 questions was created, and all questions were multiple-choice. Physicians who were contacted via social media accounts were emailed a survey link. The initial six questions assessed the demographic and professional attributes of the participants, including their age, gender, place of employment, years of medical practice, and the number of annual CS procedures performed. Question 7 was the pivotal inquiry of the study, inquiring about obstetricians’ preferred methods for closing the uterus during CS. Participants were given four options, including;’’ locked single-layer, unlocked single-layer, locked double-layer, and unlocked double-layer, “ and instructed to select one. The remaining five questions investigated surgical preferences throughout different phases of the CS, requiring a ‘yes’ or ‘no’ response.
All data analyses were performed using SPSS (Statistical Packages for the Social Sciences) software, version 22.0 (SPSS Inc., Chicago, USA). Numbers and percentages were used as descriptive statistical methods to evaluate the data. Besides, the participants were categorized into two groups based on their professional expertise, and an analysis was conducted to determine any differences in uterine closure procedures between these groups. A second analysis was also utilized based on affiliations. Categorical values were analyzed by the chi-square test. A p-value <0.05 was considered statistically significant.
Ethical Approval
This study was approved by the Ethics Committee of Lokman Hekim University, Faculty of Medicine (Date: 2025-05-01, No: 2025/184).

Results

A total of 795 physicians downloaded the survey, and 466 obstetricians responded to the survey questions. The response rate was calculated as 58.6%. The predominant age group among participants was 35-45 years, comprising 43.3% of the overall population, and only % 2.7% of physicians were older than 65. When categorized by career in the profession, 20.1% of physicians had practiced as obstetricians for less than 5 years, while 25.3% had worked in the field for over 20 years. Over fifty per cent of the physicians held the position of specialist, 10.7% were designated as associate professors, and 12.1% were classified as professors. Additionally, 52% of the participants were female, whereas 48% were male. As categorized by their respective hospitals, 15% of physicians were employed in public hospitals, 24.2% in educational and research hospitals, 18.1% in university hospitals, 24.6% in private hospitals, and 18.1% in private clinics. Furthermore, analyzing the number of CS performed by the participants in a year, 24.6% reported that they performed fewer than 50 CS annually, while 16.2% reported that they conducted more than 300 CS in a year. Demographic features and characteristics of physicians were summarized in Table 1.
Analysis of the replies to the major query of our survey about incision closure procedures in CS revealed that the predominant method adopted was the locked single layer at 75%, whilst the least favored technique was the locked double layer at 6%. Besides, 8% of physicians preferred unlocked single-layer and 11% unlocked double-layer techniques. Graph 1 illustrates participants’ preferences regarding hysterectomy closure methods.
The last five questions of our poll related to other surgical procedures involved in the CS surgery. After analyzing the responses, we revealed that 55.7% of physicians create a bladder flap and 80.8% close the parietal peritoneum routinely in CS. Also, the majority of surgeons prefer to suture subcutaneous tissues if the thickness is more than >2 cm routinely. To close the visceral peritoneum and to approximate the rectus abdominis muscles are less commonly favored methods. Questions and answers regarding preferred alternative techniques for CS in physicians are shown in Table 2.
Eventually, physicians were categorized into two categories based on their professional experience: those with less than 10 years and those with more than 10 years. The <10-year group consisted of 186 (40%) physicians, while the >10-year group comprised 280 (60%) physicians. Analysis of preferences for uterine closure procedures during cesarean section revealed no significant differences between the two groups for any technique. The locked single-layer was the most favored strategy among both senior and younger physicians. The distribution of uterine closure procedures, stratified by physicians’ years of expertise, is illustrated in Table 3. Moreover, when the techniques were assessed based on the institutions where the physicians worked, the locked-single-layer method was the most popular, with rates of 70% or above in each institution. Distribution of uterine closure procedures stratified by physicians’ affiliations is shown in Table 4.

Discussion

This survey study demonstrates that the predominant uterine closure technique among Turkish obstetricians is the locked- single-layer approach, utilized by 75% of respondents. Only less than 20% of physicians prefer the double-layer closure technique. Moreover, we have revealed no significant difference between those who had been working in the profession for more than 10 years and those who had been in the profession for the first 10 years. Also, in all institutions, more than 70% of physicians preferred the locked single-layer method.
In our survey, we also inquired about other aspects of the CS operation. We demonstrated that most of the physicians do not close the visceral peritoneum and approximate the rectus abdominis muscles. In contrast, the majority of physicians favour closing the parietal peritoneum and suturing the subcutaneous tissues if it is thick.
Over the past three decades, the prevalence of CS has been steadily rising worldwide. The average CS rate among OECD countries is approximately 29%, but significant differences exist between nations, as indicated by the 2022 data. While CS rates are below 20% in Israel and Scandinavian countries, this rate exceeds 50% in Turkey, Korea, and Chile. Sadly, Turkey
is the OECD country with the highest CS rate, nearing 60%, highlighting a serious public health concern in our country [10]. PAS rates have increased over the past two decades, especially in high-income countries, primarily due to rising CS rates [11]. PAS is a significant contributor to maternal morbidity and death, resulting in severe psychological, social, and economic issues. Although the precise cause of PAS remains unclear, insufficient healing of the hysterotomy incision after a prior CS seems to be a primary contributing factor [12]. This finding has prompted several experts to research the optimal method for closing the hysterectomy during the CS to facilitate optimal recovery and minimise the risk of PAS.
In recent years, alongside the rising incidence of CS and PAS, the optimal technique for uterine closure has emerged as a significant concern. Roberge et al. examined 20 randomised clinical trials (RCTs) and identified no statistically significant difference in cesarean scar defect and uterine dehiscence. They also determined that single-layer uterine closure was linked to a considerably reduced residual myometrial thickness [13]. Sardo et al. Evaluated 9 RCTs and 3969 CS and showed that single or double layer closure of the uterine incision is associated with a similar incidence of niche formation, as well as uterine dehiscence and uterine rupture in a subsequent pregnancy. But also, they indicated that compared with single-layer closure, double-layer closure was associated with a significantly greater residual myometrial thickness evaluated in ultrasound, which is of unclear clinical significance [14]. Finally, Verberkt et al. conducted a 2-center multicenter RCT to address the optimal uterine closure technique and allocated 2292 women. They found no superiority of double-layer uterine closure after a first CS in terms of reproductive or obstetrical outcomes at the 3-year follow-up. In addition, they conclude that in both single-layer and double-layer closure groups, gynecologic symptoms, including spotting, dysmenorrhea, and mild sexual dysfunction after CS, are highly prevalent [15]. Due to a lack of clear, sufficient data, there is currently no universally accepted evidence-based guideline regarding the technique for uterine closure in CS [16].
Although CS is the most commonly performed operation on women worldwide, significant technical discrepancies can be seen even among physicians working in the same clinic due to the lack of sufficient evidence regarding the method used to close the hysterotomy. Demers et al. conducted an anonymous survey among all active members of the Association des Obstetriciens-Gynecologues du Quebec and showed that the double-layer continuous suture was the most popular technique for 89% of respondents. Furthermore, they suggested that the use of double-layer uterine closure has increased dramatically over the last two decades. Researchers attribute this increase to the growth in vaginally birth after cesarean delivery rates during the last 20 years [17]. Kaps et al. performed an online survey of 648 obstetric hospitals in Germany. They found that 75% of participants prefer to close the uterus with the unlocked single-layer method, and less than 10% of obstetricians favored double-layer techniques [18]. In our country, in contrast to Canada and Germany, the most utilized technique was the locked single-layer technique.
We believe that the primary reasons for the widespread preference of this technique in our country are that single- layer suturing reduces operative duration and that sealing ensures improved hemostasis. Furthermore, in many education clinics in our nation, the locked-single layer approach is taught throughout residency training, and it becomes habitual.

Limitations

There are numerous weak points and limitations of our publication. First of all, despite our best efforts to reach all obstetricians in our country, we were only able to distribute the survey to 795 physicians. Unfortunately, the response rate was as low as 58.6%. Secondly, we do not know whether the practices of those participants reflect the practices of all obstetricians throughout Turkey. Nevertheless, our survey trial is the first national questionnaire on uterine closure techniques. It demonstrates the feasibility of conducting national online surveys on obstetric topics and facilitates the discussion of the necessity of establishing a standardized uterine closure technique during CS.

Conclusion

In this nationwide online survey, we demonstrated that the most common technique for uterine closure in CS is the locked single-layer method. Furthermore, the majority of clinicians close the parietal peritoneum and suture subcutaneous tissue if it is thick. Additionally, no difference was found between senior physicians and less experienced physicians in terms of uterine closure methods. Considering that our nation ranks among the top globally in CS rates, it is evident that more efforts are required to identify the optimal uterine closure technique and to promote it uniformly across the country.

References

1. Betran AP, Ye J, Moller AB, Souza JP, Zhang J. Trends and projections of caesarean section rates: global and regional estimates. BMJ Glob Health. 2021;6(6):e005671.
   Article PubMed Google Scholar
2. Lin PL, Hou JH, Chen CH. A common problem between gynecology, obstetrics, and reproductive medicine: cesarean section scar defect. Taiwan J Obstet Gynecol. 2024;63(4):459-70.
   Article PubMed Google Scholar
3. Tower AM, Frishman GN. Cesarean scar defects: an underrecognized cause of abnormal uterine bleeding and other gynecologic complications. J Minim Invasive Gynecol. 2013;(5):562-72.
   Article PubMed Google Scholar
4. Premkumar A, Huysman B, Cheng C, Einerson BD, Moayedi G. Placenta accreta spectrum in the second trimester: a clinical conundrum in procedural abortion care. Am J Obstet Gynecol. 2025 232(1):92-101.
   Article PubMed Google Scholar
5. Verberkt C, Lemmers M, de Vries R, Stegwee SI, de Leeuw RA, Huirne JAF. Aetiology, risk factors and preventive strategies for niche development: a review. Best Pract Res Clin Obstet Gynaecol. 2023;90:102363.
   Article PubMed Google Scholar
6. Mohr-Sasson A, Castel E, Cohen A,et al. The association of endometrial closure during cesarean section to the risk of developing uterine scar defect: a randomized control trial. Arch Gynecol Obstet. 2024;309(5):2063-70.
   Article PubMed Google Scholar
7. Amyx M, Philibert M, Farr A, et al. Trends in caesarean section rates in Europe from 2015 to 2019 using Robson’s Ten Group Classification System: a Euro- Peristat study. BJOG. 2024;131(4): 444-54.
   Article PubMed Google Scholar
8. Boerma T, Ronsmans C, Melesse DY, et al. Global epidemiology of use of and disparities in caesarean sections. Lancet. 2018;392(10155):1341-8.
   Article PubMed Google Scholar
9. Boatin AA, Schlotheuber A, Betran AP, Moller AB, Barros AJD, Hosseinpoor AR. Within country inequalities in caesarean section rates: observational study of 72 low and middle income countries. BMJ. 2018;360:155-9.
   Article PubMed Google Scholar
10. Liu B, Abdi MA, Ma Y. Trend of cesarean section rates and related factors among first-time mothers with single pregnancies in Zhejiang Province, China: evidences from a multi-centre study. Int J Womens Health. 2025;17:1681-92.
    Article PubMed Google Scholar
11. Jauniaux E, Jurkovic D, Hussein AM, Burton GJ. New insights into the etiopathology of placenta accreta spectrum. Am J Obstet Gynecol. 2022;227(3):384-91.
    Article PubMed Google Scholar
12. Jauniaux E, Collins S, Burton GJ. Placenta accreta spectrum: pathophysiology and evidence-based anatomy for prenatal ultrasound imaging. Am J Obstet Gynecol. 2018;218(1):75-87.
    Article PubMed Google Scholar
13. Roberge S, Demers S, Berghella V, Chaillet N, Moore L, Bujold E. Impact of single- vs double-layer closure on adverse outcomes and uterine scar defect: a systematic review and metaanalysis. Am J Obstet Gynecol. 2014;211(5):453-60.
    Article PubMed Google Scholar
14. Di Spiezio Sardo A, Saccone G, McCurdy R, Bujold E, Bifulco G, Berghella V. Risk of cesarean scar defect following single- vs double-layer uterine closure: systematic review and meta-analysis of randomized controlled trials. Ultrasound Obstet Gynecol. 2017;50(5):578-83.
    Article PubMed Google Scholar
15. Verberkt C, Geomini PMAJ, Van Eekelen R, et al. Huirne JAF;single-layer vs double-layer uterine closure during cesarean delivery: 3-year follow-up of a randomized controlled trial (2Close study). Am J Obstet Gynecol. 2024;231(3):346. e1-346.e11.
    Article PubMed Google Scholar
16. Caughey AB, Nelson G, Wilson RD, et al. Guidelines for intraoperative care in cesarean delivery: enhanced recovery after surgery society recommendations (Part 2). Am J Obstet Gynecol. 2018;219(6):533-44.
    Article PubMed Google Scholar
17. Demers S, Roberge S, Afiuni YA, Chaillet N, Girard I, Bujold E. Survey on uterine closure and other techniques for caesarean section among Quebec’s obstetrician- gynaecologists. J Obstet Gynaecol Can. 2013;35(4):329-33.
    Article PubMed Google Scholar
18. Kaps C, Schwickert A, Dimitrova D, et al. Online survey on uterotomy closure techniques in caesarean section. J Perinat Med. 2021;49(7):809-17.
    Article PubMed Google Scholar

Declarations

Additional Information

Publisher’s Note
Bayrakol MP remains neutral with regard to jurisdictional and institutional claims.

Rights and Permissions

Creative Commons License

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License (CC BY-NC 4.0). To view a copy of the license, visit https://creativecommons.org/licenses/by-nc/4.0/

View full license details →

About This Article