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Review
. 2025 Oct;312(4):1095-1106.
doi: 10.1007/s00404-025-08151-y. Epub 2025 Aug 20.

Single-versus double-layer uterine closure at the time of cesarean delivery and risk of uterine scar niche: a systematic review and meta-analysis of randomized trials

Mattia Dominoni  1   2 , Marco Torella  3 , Rossella Molitierno  3 , Mario Fordellone  4 , Gabriele Saccone  5 , Dario Colacurci  6 , Antonio Simone Laganà  7 , Martina Rita Pano  8   9 , Barbara Gardella  1   2 , Marco La Verde  3
Affiliations
Review

Single-versus double-layer uterine closure at the time of cesarean delivery and risk of uterine scar niche: a systematic review and meta-analysis of randomized trials

Mattia Dominoni et al. Arch Gynecol Obstet. 2025 Oct.

Abstract

Objective: This systematic review and meta-analysis compared single- versus double-layer uterine closure at the time of cesarean delivery.

Data sources: MEDLINE, EMBASE, Scopus, ClinicalTrials.gov, and Cochrane Central Register of Controlled Trials were searched from inception until May 2024.

Study eligibility criteria: We included only randomized controlled trials (RTSs) that compared single-layer versus double-layer uterine closure at the time of cesarean delivery.

Study appraisal and synthesis methods: Outcomes were analyzed using a random-effects model. Results are expressed as risk differences. The assessment of the risk of bias was performed by using the Risk of Bias 2 tool. The primary outcome was the incidence of scar defects (i.e., niche) at 6 months after delivery. The secondary outcomes were incidence of scar defects at 6 weeks and 3 months.

Results: A total of 18 studies were identified by the systematic review; 11 RCTs involving 6,058 participants were included in the meta-analysis. There is no statistical difference between single-layer and double-layer uterine closure of cesarean delivery incision regarding the incidence of uterine scar defect at six weeks. Single-layer closure showed a significantly lower incidence of niche after three months (RD = - 0.02 (- 0.06, 0.02); I2 = 81%, p < 0.01), and six months (RD = - 0.11, CI - 0.15, - 0.07, I2 = 91%, p < 0.01).

Conclusions: Single-layer uterine closure at the time of cesarean delivery resulted in a lower uterine scar defects after three and six months compared to double-layer uterine closure.

Systematic review registration: PROSPERO, Unique identifier: CRD42024552495.

Keywords: Cesarean; Cesarean section; Double-layer; Isthmocele; Niche; Scar defects; Single-layer; Ultrasound; Uterine closure; Uterine scar defect.

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Conflict of interest statement

Declarations. Conflict of interest: The authors declare no competing interests. Ethical approval: This protocol did not require human or animal ethics approval.

Figures

Fig. 1
Fig. 1
PRISMA flow chart of included studies
Fig. 2
Fig. 2
Summary of the Risk of bias according to Cochrane Handbook in randomized controlled trials included in meta-analysis
Fig. 3
Fig. 3
Figure 2 Risk of bias according to Cochrane Handbook in randomized controlled trials included in meta-analysis
Fig. 4
Fig. 4
Forest plots showed niche incidence at six weeks post-cesarean section
Fig. 5
Fig. 5
Forest plots showed niche incidence at three months post-cesarean section
Fig. 6
Fig. 6
Forest plots showed niche incidence at six months post-cesarean section
See this image and copyright information in PMC

References

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