What suture materials and sizes are used for each layer of the abdomen during a caesarean section?

Suture Materials and Sizes for Caesarean Section Abdominal Closure

For caesarean section, use delayed absorbable sutures (polyglactin 910/Vicryl, poliglecaprone-25/Monocryl, or chromic catgut) for the uterine closure in 1-2 layers, avoid closing the peritoneum entirely, reapproximate subcutaneous tissue ≥2 cm with absorbable suture, and close skin with subcuticular absorbable suture—specific suture sizes are typically 0 or 1 for uterine closure, 2-0 or 3-0 for subcutaneous tissue, and 3-0 or 4-0 for skin closure. 1, 2, 3

Layer-by-Layer Approach

Uterine Closure (Hysterotomy)

• Suture material: Delayed absorbable monofilament (Monocryl/poliglecaprone-25), polyglactin 910 (Vicryl), or chromic catgut are all acceptable options with no strong evidence favoring one over another 1, 2, 3
• Suture size: Typically 0 or 1 (though guidelines do not specify exact sizes, this is standard surgical practice)
• Technique: Two-layer closure may be associated with lower uterine rupture rates in subsequent pregnancies, though evidence quality is low 1, 2, 3
• Important note: The most recent Cochrane review found no difference in outcomes between 1- or 2-layer closure, but two-layer closure remains reasonable when future pregnancy and trial of labor after cesarean are anticipated 1, 2

Peritoneum (Visceral and Parietal)

• Recommendation: Do NOT close the peritoneum 1, 3
• Rationale: Peritoneal closure provides no benefit in terms of outcomes, increases operative time, and systematic reviews show no difference in intraabdominal adhesions 1
• Evidence strength: This is a strong recommendation with moderate certainty of evidence 1

Rectus Muscles

• Recommendation: Do NOT suture the rectus muscles at the midline 1
• Rationale: There is no evidence to support closure, and intramuscular sutures will tear through muscle tissue 1

Abdominal Fascia

• Suture material: Slowly absorbable suture is preferred over rapidly absorbable suture 1
• Suture size: Typically size 1 or 0 (standard for fascial closure)
• Technique: Use continuous closure with a suture-to-wound length ratio of at least 4:1 (Jenkins Rule) to reduce incisional hernia and wound complications 1
• Mass vs. layered closure: Mass closure (single layer including all fascial layers) is preferred because it is faster with no additional complications demonstrated 1

Subcutaneous Tissue

• Recommendation: Reapproximate subcutaneous tissue if depth is ≥2 cm 1, 3
• Suture material: Absorbable suture such as polyglactin 910 (Vicryl) or poliglecaprone-25 (Monocryl) 4
• Suture size: 2-0 or 3-0 5, 4
• Evidence: Closure of subcutaneous tissue ≥2 cm reduces wound complications with moderate evidence quality 1, 3

Skin Closure

• Suture material: Subcuticular absorbable suture is strongly preferred over staples 1, 3
• Suture size: 3-0 or 4-0 6, 5
• Specific options: Both 4-0 Vicryl and 4-0 Monocryl show comparable rates of surgical site infection and wound complications 6
• Enhanced option: Consider triclosan-coated Vicryl (Vicryl Plus) when available, as it reduces surgical site infections (OR 0.62,95% CI 0.44-0.88) 3
• Evidence: Subcuticular suture closure reduces wound separation compared to staples removed 4 days after surgery, with improved patient preference and experience scores 1, 3

Critical Technical Considerations

Suture-to-Wound Length Ratio

• Maintain a ratio of at least 4:1 for fascial closure to significantly reduce incisional hernia and wound complications 1
• Document this ratio at every wound closure 1

Needle Type

• Blunt needles reduce glove perforations (RR 0.54,95% CI 0.41-0.71) but show no patient benefit and lower provider satisfaction 1, 2
• Choice between blunt and sharp needles can be based on provider preference and safety considerations 1, 2

Common Pitfalls to Avoid

• Do not close the peritoneum: This wastes time and provides no benefit 1, 3
• Do not use rapidly absorbable sutures for fascia: Slowly absorbable sutures show trends toward fewer incisional hernias 1
• Do not skip subcutaneous closure if tissue ≥2 cm: This significantly reduces wound complications 1, 3
• Avoid overly tight sutures: These can strangulate tissue and impair healing 3