Cesarean delivery: the technique used for closing the uterus must be reconsidered

The most common technique used for closing the uterus after a cesarean delivery causes so many long-term complications that it’s time to question its use. That’s the conclusion reached by two world-renowned specialists in obstetrics and gynecology in an article published in a special issue of the American Journal of Obstetrics & Gynecology on cesarean delivery. The authors argue in favor of replacing the current approach with a closure technique that respects the natural anatomical structure of the uterus.

The authors, Dr Emmanuel Bujold, professor at Université Laval's Faculty of Medicine and researcher at the CHU de Québec-Université Laval Research Center, and Dr Roberto Romero, Head of the Pregnancy Research Branch at the NICHD/National Institutes of Health in US, list the many long-term complications associated with cesarean delivery and their incidence according to an exhaustive review of the scientific literature on the topic.

Complications that may arise during subsequent deliveries include abnormal attachment of the placenta to the uterus (up to 6% of women), which increases the risk of severe hemorrhage and hysterectomy; uterine rupture (up to 3%), which can lead to the death of the newborn; and prematurity (up to 28%). Women's health can also be impacted because of pelvic pain (up to 35%), postmenstrual bleeding (up to 33%), and endometriosis/adenomyosis (up to 43%).

The technique used for the past 50 years to close the uterus after a cesarean delivery involves sutures that pass through and join the uterine lining and the muscles surrounding it, explains Professor Bujold. "This method has the advantage of being simple and quick, which limits bleeding in the mother. This is undoubtedly why it has been widely adopted by obstetrician-gynecologists. However, the scar tissue produced by this type of closure does not restore the anatomical and functional integrity of the uterus, notes the scientist. When you stop to think about it, it's not surprising. For example, when someone has a laceration on their cheek, you don't close it by suturing the oral mucosa, muscles, and skin together. There's no reason to do that with the uterus.”

The closure technique proposed by Drs Bujold and Romero consists of suturing together tissues of the same type. The muscle layer of the uterus is sutured in two places, with one suture in the upper part and the other in the lower part. A third suture is made to close the envelope surrounding the organ. “We do not operate on the uterine lining so as not to interfere with its natural regeneration,” explains Bujold.

Globally, one child is born by cesarean every second, the researcher points out. In Canada, approximately 27% of children are born by cesarean, nearly double the rate observed three decades ago. “Given the high frequency of cesarean and their long-term health consequences for women, finding solutions should be considered a public health priority,” says Bujold.

The disadvantage of the approach recommended by Bujold and Romero is that it takes a little longer. “The standard closure technique takes between 2 and 3 minutes, while the one we propose takes 5 to 8 minutes. The resulting additional blood loss is marginal. Our position is that meticulous and adequate restoration of the uterine structure is more important than the speed of the procedure. The future reproductive health of women who undergo cesarean must be the priority,” concludes the researcher.

Reference:

Bujold, Emmanuel et al., Uterine closure after cesarean delivery: surgical principles, biological rationale, and clinical implications, American Journal of Obstetrics and Gynecology, DOI:10.1016/j.ajog.2025.10.007.