What type of sutures are used for two-layer suturing of the uterus in cesarean deliveries?

Suture Types for Two-Layer Uterine Closure in Cesarean Delivery

For two-layer uterine closure during cesarean delivery, delayed absorbable monofilament sutures (such as Monocryl/poliglecaprone-25), chromic catgut, or polyglactin 910 (Vicryl) are all acceptable options, though no strong evidence supports superiority of any particular suture material. 1

Evidence-Based Suture Selection

Commonly Used Suture Materials

The Enhanced Recovery After Surgery (ERAS) Society guidelines identify three main suture types used for uterine closure, all without definitive evidence favoring one over another: 1

• Delayed absorbable monofilament (Monocryl/poliglecaprone-25) - synthetic monofilament with predictable absorption 1
• Chromic catgut - natural absorbable suture with variable absorption rates 1
• Polyglactin 910 (Vicryl) - synthetic braided absorbable suture 1

Monofilament vs Multifilament Considerations

Recent research comparing monofilament versus multifilament sutures found no significant differences in clinical outcomes: 2

• No difference in cesarean scar defect rates at 6 months (18.4% monofilament vs 23.4% multifilament, p=0.31) 2
• Similar residual myometrial thickness (7.6 mm vs 7.2 mm) 2
• No difference in postoperative symptoms including pelvic pain, dysmenorrhea, or dyspareunia 2

Two-Layer Closure Rationale

When to Consider Two-Layer Closure

Two-layer closure may be associated with lower rates of uterine rupture in subsequent pregnancies, though the evidence quality is low. 1

The ERAS Society guidelines note: 1

• Historical preference for two-layer closure based on nonrandomized trial evidence suggesting higher uterine rupture rates with single-layer closure 1
• The most recent Cochrane review found no difference in outcomes between one- or two-layer closure 1
• Two-layer closure remains a reasonable option when future pregnancy and TOLAC (trial of labor after cesarean) are anticipated 1

Practical Surgical Considerations

Regardless of suture material chosen for two-layer closure: 3

• Use blunt expansion of the transverse uterine hysterotomy rather than sharp extension to reduce blood loss 3
• Avoid peritoneal closure as it does not improve outcomes and increases operative time 1
• Reapproximate subcutaneous tissue if ≥2 cm thick to reduce wound complications 1

Common Pitfalls to Avoid

• Do not assume suture material significantly impacts uterine healing - the evidence shows clinical equivalence between commonly used absorbable sutures 2
• Avoid sharp needle extension of the hysterotomy - blunt expansion reduces blood loss without compromising outcomes 3
• Do not routinely close the peritoneum - this adds operative time without benefit 1
• Consider patient-specific factors such as obesity (requiring thicker suture gauge) or bleeding risk (may benefit from two-layer closure) 3

Needle Type Considerations

Studies comparing blunt versus sharp needles show: 1

• Reduced glove perforations with blunt needles (RR 0.54,95% CI 0.41-0.71) 1
• No demonstrated benefit to patients in terms of healing or complications 1
• Lower provider satisfaction with blunt needles 1