Variations in uterine closure technique: an institutional survey of obstetricians and implications for patient counseling and prevention of adverse sequelae

Abstract

Objectives To assess the diversity of uterine closure techniques (UCTs) among providers in one institution and evaluate concurrent consideration of adverse outcomes for patient counseling, provisional care, and prevention. Methods Forty-four obstetricians at NYU Langone Health were emailed a survey of their uterine closure technique, patient counseling, and practice experience. Results were stratified by years of practice: ≤5, 5–20, and 20–40 years. Results Thirty-nine obstetricians (88.6%) completed the survey. Among those, a blunt uterine opening was preferred by 29 (74.4%), and a mid-lower segment location was favored by 34 (87.2%). At uterine closure, the endometrium was included by 20 (51.3%), with half a centimeter or more incorporated in the myometrial closure, whereas 15 (38.5%) did not factor in the endometrium’s presence. Closure duration varied from 1 to 20 min, with 21 (53.9%) lasting 1–5 min and 12 (30.8%) lasting 5–10 min. All physicians were familiar with the potential post-cesarean complications and counseled their patients accordingly; 25 (64.1%) at the first post-op visit while 14 (35.9%) did so before the next conception. Practitioners with fewer years in practice endorsed the safety of up to five consecutive cesarean births, while those with more experience approved up to ten. Thirty-two obstetricians (82.1%) stated that the risk of abnormal placentation is exclusively associated with the number of cesarean sections, whereas five (12.8%) senior obstetricians asserted that individual surgical techniques are most impactful. Conclusions The survey illustrates that various UCTs are performed irrespective of potential adverse sequelae and without consideration for subsequent patient counseling and care. Ongoing research must study the impact of UCT on scar healing to formulate preventive strategies for post-cesarean complications.

The Impact of Uterine Incision Closure Techniques on Post‐cesarean Delivery Niche Formation and Size

“…24 This technique contrasts with other obstetric providers who utilize single-or double-layer uterine closure without specific concern for endometrial exclusion or inclusion. 25 Women who underwent EFCT at their primary CDs were more likely to heal with a small to no residual uterine scar defect than those with a routine closure, whether by a double-or single-layer technique. Additionally, the defect size was comparably smaller in the EFCT subgroup and the RMT significantly larger.…”

“…A recent survey highlights the variety and technical differences of double-and single-layer closure, endometrium exclusion, and inclusion among practicing obstetricians in one institution and their perceived association with post-cesarean complications. 25 Our study emphasizes needle and suture placement at the endo-myometrial junction along the margins of the entire uterine incision, leaving the apposed decidua approximated and excluded from the myometrial closure. It aligns with published clinical data regarding women who underwent an EFCT cesarean incision closure and experienced no abnormal placental implantation in subsequent pregnancies.…”

“…Surgical management of niches includes the use of hysteroscopy, laparoscopy, and robotic instrumentation 40,41 . To mitigate the above and advance toward long‐term solutions, we must examine the finer details of the EFCT as well as other surgical techniques and consider the autonomy of providers 15,25 …”

“…40,41 To mitigate the above and advance toward long-term solutions, we must examine the finer details of the EFCT as well as other surgical techniques and consider the autonomy of providers. 15,25…”

“…In this study, the EFCT approach is exclusively used by the authors and is employed to optimally restore normal anatomy while also bolstering the structural integrity of the uterine wall 24 . This technique contrasts with other obstetric providers who utilize single‐ or double‐layer uterine closure without specific concern for endometrial exclusion or inclusion 25 . Women who underwent EFCT at their primary CDs were more likely to heal with a small to no residual uterine scar defect than those with a routine closure, whether by a double‐ or single‐layer technique.…”