Ultrasound Evaluation of the Uterine Scar
After Cesarean Delivery
A Randomized Controlled Trial of One- and Two-Layer Closure
Benjamin D. Hamar, MD, Shelley B. Saber, MD, Michael Cackovic, MD, Lissa K. Magloire,
Christian M. Pettker, MD, Sonya S. Abdel-Razeq, MD, Victor A. Rosenberg, MD,
Irina A. Buhimschi, and Catalin S. Buhimschi, MD
OBJECTIVE: To survey the uterine scar thickness by ultra-
sonography in women randomly assigned to one- or two-
layer hysterotomy closure after primary cesarean delivery.
METHODS: This was a randomized, blinded trial of uter-
ine scar closure with ultrasonographic follow-up. Thirty
consecutive patients undergoing primary cesarean deliv-
ery were enrolled and randomly assigned to one- or
two-layer closure of the hysterotomy. Ultrasound surveil-
lance of the uterine scar thickness was performed at
baseline (before surgery) and 48 hours, 2 weeks, and 6
weeks post partum.
RESULTS: Patient compliance with the postpartum sur-
veillance protocol was 90%, and the uterine scar was
visualized in 99% of attempted ultrasonographic exami-
nations. There were no differences between groups at
baseline or at any of the follow-up evaluations. An initial
5- to 6-fold increase in uterine scar thickness was ob-
served, followed by a gradual decrease with the 6-week
measurements still thicker than baseline. Repeated mea-
sures analysis of variance showed significant variation
across time points starting either at baseline (P<.001) or
at 48 hour postoperatively (P<.001), but this variation did
not depend on closure type (Pⴝ.79 for all visits and Pⴝ.81
beginning with 48-hour postoperative time point).
From the Yale School of Medicine, Department of Obstetrics, Gynecology, and
Reproductive Biology, New Haven, Connecticut.
Initially presented at the Society for Maternal–Fetal Medicine 27th Annual
Meeting, February 5–10, 2007, San Francisco, California.
The authors thank Jim Dziura, PhD, of Yale University for his assistance with
part of the statistical analysis.
Corresponding author: Benjamin Hamar, MD, Beth Israel-Deaconess Medical
Center, 330 Brookline Avenue, Boston, MA 02215; e-mail: bhamar@bidmc.
harvard.edu.
Financial Disclosure
The authors have no potential conflicts of interest to disclose.
© 2007 by The American College of Obstetricians and Gynecologists. Published
by Lippincott Williams & Wilkins.
ISSN: 0029-7844/07
808 VOL. 110, NO. 4, OCTOBER 2007
MD,
CONCLUSION: The process of uterine scar remodeling
can be successfully monitored by ultrasonography. Uter-
ine scar thickness diminishes progressively after both
one- or two-layer closure but does not vary with mode of
hysterotomy closure. The uterine scar thickness remains
increased even at 6 weeks post partum, suggesting that
the process of uterine scar remodeling extends beyond
the traditional postpartum period.
CLINCAL TRIAL REGISTRATION: ClinicalTrials.gov, www.
clinicaltrials.gov, NCT00224250
(Obstet Gynecol 2007;110:808–13)
LEVEL OF EVIDENCE: I
C esarean delivery has become more common,
with primary cesarean delivery rates increasing
from 21.2% in 1996 to 27.1% in 2003.1 Over the same
interval, vaginal birth after cesarean birth has de-
creased from 28.3% to 10.6%.1 This decrease may be
attributed to concerns regarding the risks during trials
of labor, such as uterine rupture, estimated to occur in
0.3– 4.0% of pregnancies with history of cesarean
delivery.2–7 The risk for poor obstetric outcome in a
subsequent pregnancy has been shown to be related
to surgical technique, with classical cesarean delivery
having the highest risk for rupture and lower segment
incisions having a lower risk.8
Currently, a low-transverse incision is the pre-
ferred method of hysterotomy during cesarean deliv-
ery. This incision has traditionally been repaired with
a two-layer closure, although a one-layer closure has
been shown to be as effective for surgical closure and
hemostasis,9 with the advantages of shorter operative
time, decreased blood loss, lower rates of endometri-
tis, and shorter hospital stay.10 A one-layer closure
usually involves a single continuous, locking layer of
absorbable suture. A two-layer closure typically adds
an imbricating layer of absorbable suture. Substantial
OBSTETRICS & GYNECOLOGY
research effort has attempted to estimate whether
one- or two-layer closure provides better outcomes
and a lower risk for uterine rupture in subsequent
pregnancies.10 –13 Several studies have shown an in-
crease in uterine scar disruption for one-layer clo-
sure10,13 while others have shown no effect.11,12 Impor-
tantly these research efforts have been limited by their
retrospective nature and the biases inherent in study-
ing surgical technique with these methods.
To assess the risk of uterine rupture in a subse-
quent pregnancy, researchers have used ultrasonog-
raphy in the evaluation of the uterine scar in the
second14 and third trimesters15–18 as well as the post-
partum period.19 It has generally been found that the
thicker the uterine scar the lower the rate of complica-
tions.14 –16,18,19 One may postulate that a thicker scar is
stronger, and thus performs better, than a thinner one.
Whether thickness of the uterine scar varies with the
technique used at the time of hysterotomy closure is
an unexplored question.
Our hypothesis is that uterine scar thickness is
unaffected by the type of hysterotomy closure (one-
versus two-layer). We performed a randomized trial
of hysterotomy closure at primary cesarean delivery
using one- versus two-layer technique, with a prospec-
tive blinded ultrasonographic follow-up of the uterine
scar.
MATERIALS AND METHODS
Patients were identified as potential study subjects if
they were to have a term primary cesarean delivery at
term at Yale-New Haven Hospital between January
2005 and June 2006. Patients were approached for
participation if their delivery was a scheduled primary
cesarean delivery or a nonemergent cesarean delivery
in labor. Exclusion criteria were multiple gestations, a
pain score greater than 4 out of 10, abnormalities of
fetal heart rate (variable or late decelerations), prior
uterine surgery, hydramnios, uterine malformation,
maternal diabetes, connective tissue disorders, and
non-English language. Before initiation of the study,
random allocation was performed using premade
allocation cards (N⫽30), specifying “one-layer” or
“two-layer,” sorted in blocks of 10 and placed into
sequentially numbered, sealed, opaque envelopes.
After obtaining written consent and confirming entry
into the study, each patient was assigned a treatment
group by selection of the next consecutive envelope.
The group allocation was revealed to the surgeon
during the surgery just before the hysterotomy repair.
The Yale Human Investigation Committee ap-
proved the research protocol and consent process.
Patients randomly assigned to one-layer closure had
VOL. 110, NO. 4, OCTOBER 2007 Hamar et al
their hysterotomy closed in one layer with a running,
locking suture of 0-Polysorb (coated, braided glycolide/
lactide polymer; U.S. Surgical, Norwalk, CT).
Patients randomly assigned to a two-layer closure
had an initial closure identical to the one-layer closure
as above. An additional layer of 0-Polysorb suture was
used to imbricate the first layer in a continuous,
nonlocking suture.
All closures were performed by one of the inves-
tigators according to a study protocol. For each
patient, additional hemostatic sutures were placed at
the discretion of the operating physician, and the
number of additional sutures was recorded. Also
recorded prospectively were labor at time of cesarean
delivery, clinical chorioamnionitis or endometritis as
assessed by the treating physician, estimated blood
loss at surgery, hematocrit change (preoperative mi-
nus 24 hours postoperative), duration of surgery, birth
weight, sex of newborn, and whether the mother was
breastfeeding. All patients received a single dose of a
first-generation cephalosporin antibiotic (or equiva-
lent if penicillin allergic) at umbilical cord clamping
per hospital protocol.
Patients had an evaluation of the lower uterine
segment immediately preoperative (baseline) and
then follow-up measurements at 48 hours, 2 weeks,
and 6 weeks postoperatively according to a study
protocol. Baseline measurements were obtained by
measuring the myometrial thickness in the midsagittal
plane by transabdominal ultrasonography at a point
below the reflection of the bladder in a technique
described by Buhimschi et al20 and illustrated in
Figure 1. Previously published reports have shown
that the lower uterine segment thickness measured by
ultrasonography is not altered by labor status.20 Post-
operative evaluation of the uterine incision involved
identifying the uterine scar as described by Koutsoug-
eras et al19 and measuring the scar in the midsagittal
plane perpendicular to the uterine wall by transab-
dominal or transvaginal approach. The scar was
identified by a discontinuity in the architecture of the
uterus in the midsagittal plane and was manifest by
either a hyperechoic or hypoechoic line perpendicu-
lar to the wall of the uterus. A transabdominal ap-
proach was attempted, but if the scar was poorly
visualized, transvaginal ultrasonography was used.
Measurements were done by one of the investigators
(B.D.H., S.B.S., or C.S.B.) who were blinded to the
allocation group for hysterotomy closure. Previous
studies by our group have validated the interobserver
and intraobserver variability of these measurements
taken by this method.20
Ultrasonography of Uterine Scar After Cesarean 809
Fig. 1. Measurement of the preoperative myometrial thick-
ness by ultrasonography in the midsagittal plane. B, blad-
der; F, fetus in amniotic cavity.
Hamar. Ultrasonography of the Uterine Scar After Cesarean.
Obstet Gynecol 2007.

Measurements were carried out using GE Logiq 3

or GE Voluson 730 ultrasound machine (GE Health-
care, Chalfont St. Giles, United Kingdom) using a 3-
to 5-MHz or 4- to 7-MHz transabdominal transducer
or a 5- to 9-MHz transvaginal transducer as necessary.
A sample size calculation was performed to esti-
mate the required number of participants. Based on
available data,20 to detect a 10% difference in myome-
trial thickness between groups or between study periods
with 80% power and ␣⫽0.05, it was anticipated that 30
subjects (15 per closure group) would be required.
Data were tested for normality using the Kolmog-
orov-Smirnov method and reported as either mean
and 95% confidence interval (CI) (for normally dis-
tributed data) or as median and interquartile range
(IQR) (for skewed data). Comparisons between two
groups were performed using Student t tests or Mann-
Whitney rank sum tests as appropriate. Two-tailed Fig. 2. Flow diagram of the recruitment and follow-up of the
analysis was performed in all cases. Multiple compar- study population.
ison procedures were performed using repeated mea- Hamar. Ultrasonography of the Uterine Scar After Cesarean.
Obstet Gynecol 2007.
sures analysis of variance followed by Tukey or
Dunn’s post hoc comparisons as appropriate. Propor-
tions were compared with ␹2 or Fisher exact test as RESULTS
appropriate. Statistical analyses was performed using Thirty patients were recruited and randomly assigned
SPSS 11.0.4 (SPSS, Inc, Chicago, IL). Sample size and to one- or two-layer closure (15 per group, Fig. 2).
power analysis calculations were performed using Demographic data revealed that the women in the
JMP 5.0 (SAS Institute, Inc, Chicago, IL). Throughout one-layer group were significantly older, but that
our analyses, we considered a P value ⬍.05 to indicate there were no other significant demographic differ-
statistical significance, and all analyses were based on ences between groups (Table 1).
an intention-to-treat. All patients had the allocated closure. In 8 (53%)

810 Hamar et al Ultrasonography of Uterine Scar After Cesarean OBSTETRICS & GYNECOLOGY
Table 1. Demographic and Clinical Characteristics of Women (at Enrollment)
One-Layer Two-Layer
Closure (nⴝ15) Closure (nⴝ15) P
Age (y)* 30⫾7 25⫾7 .02
Gravidity† 2 (1–3) 1 (1–3) .63
Parity† 0 (0–1) 0 (0–1) .32
Nulliparity‡ 11 (73) 8 (53) .26
Gestational age (wk)* 39.3⫾0.5 38.6⫾0.9 .12
Contraindication to vaginal delivery‡ 10 (67) 8 (53) .46
Labor at time of delivery‡ 5 (33) 8 (53) .27
* Data presented as mean⫾standard deviation and analyzed with Student t test.
†
Data presented as median (interquartile range) and analyzed with Mann-Whitney U Test.
‡
Data presented as n (%) and analyzed with ␹2 and Fisher exact tests where appropriate.

of the one-layer closure cases, the surgeon deemed it
necessary to use additional hemostatic sutures com-
pared with 4 (27%) of the two-layer closure group
(P⫽.14). There were no significant differences seen in
estimated blood loss, hematocrit change, operative
time, or other intraoperative data (Table 2). There
were no intraoperative complications in either group.
In all, 90% of follow-up visits were kept and the
uterine scar was visualized in 99% of the visits (repre-
sentative image in Figure 3). Repeated measures analy-
sis of variance, showed significant variation across time
points compared with either lower segment thickness at
baseline (P⬍.001) or with scar thickness at 48 hours
postoperatively (P⬍.001), but that this variation did not
depend on closure type (P⫽.79 for all visits and P⫽.81
beginning with 48 hour postoperative time point) (Fig.
4). Within each measurement set, the thickness of the
lower segment and scar showed no differences between
groups at baseline (median [95% CI], one-layer: 4.9
[3.9 – 6.0] mm compared with two-layer: 4.9 [4.5–5.4]
mm, P⫽.97), at 48 hours (one-layer: 25.4 [21.2–29.7]
mm compared with two-layer: 30.3 [27.5–33.0] mm,
P⫽.09), at 2 weeks (one-layer: 17.1 [15.3–19.0] mm
compared with two-layer: 16.6 [14.8 –18.4] mm, P⫽.75),
or at 6 weeks (one-layer: 13.0 [10.8 –15.3] mm com-
pared with two-layer: 14.1 [11.4 –16.8] mm, P⫽.61). For
both closure techniques, there was an initial 5- to 6-fold
increase in scar thickness at 48 hours postpartum
(P⬍.001) compared with the preoperative myometrial
thickness. This initial increase was followed by a gradual
reduction in thickness of the scar site. However, we
found that, even at 6 weeks post partum, the uterine wall
at the site of the scar was significantly thicker than before
surgery, irrespective of the closure technique.
DISCUSSION
Our results demonstrate that, in the immediate post-
operative period, it is possible to follow the progres-
sion of scar morphology by ultrasonography. In
women who have primary cesarean delivery, there is
an immediate increase in the thickness of the
uterine scar compared with the preoperative myo-
metrial thickness, and then a gradual decrease as
the scar is remodeled. These changes in the scar
thickness are independent of the method of closure
(one- compared with two-layer) and confirm our
original hypothesis.
Prior efforts with ultrasound evaluation of the
uterine scar have focused on antepartum assessment,
and less on postpartum evaluation of the hysterotomy

Table 2. Operative Characteristics and Birth Outcomes

One-Layer Two-Layer
Closure (nⴝ15) Closure (nⴝ15) P
Clinical chorioamnionitis* 3 (20) 6 (40) .43
Additional sutures necessary* 8 (53) 4 (27) .14
Estimated blood loss (mL)† 616⫾130 613⫾154 .95
Change in hematocrit over 24 h (%)† 5.3⫾2.6 5.5⫾2.4 .92
Time in operating room (min)† 55⫾15 58⫾12 .56
Birth weight (g)† 3,352⫾753 3,442⫾430 .70
Male infant* 9 (60) 6 (40) .27
Breastfed infant* 8 (53) 6 (40) .46
Measurement by transabdominal approach* 45 (83) 45 (85) .82
* Data presented as n (%) and analyzed with ␹2 and Fisher exact tests where appropriate.
†
Data presented as mean⫾standard deviation and analyzed with Student t test.

VOL. 110, NO. 4, OCTOBER 2007 Hamar et al Ultrasonography of Uterine Scar After Cesarean 811

Fig. 3. Ultrasound follow-up of the uterine scar at 6 weeks
cesarean delivery by transabdominal approach. B, bladder;
U, uterus. The scar is between the two arrows.
Hamar. Ultrasonography of the Uterine Scar After Cesarean.
Obstet Gynecol 2007.
Fig. 4. Graph of mean uterine (baseline) and scar (48 hours,
2 weeks, and 6 weeks) thickness by closure type. Data
presented as mean (mm) with 95% confidence intervals
(CI).
Hamar. Ultrasonography of the Uterine Scar After Cesarean.
Obstet Gynecol 2007.
incision repair stratified by closure technique. For
example, investigators have elucidated the natural
history of scar thickness in women with a prior uterine
scar21 and found a correlation between ultrasono-
graphic and clinically determined thickness at cesar-
812 Hamar et al Ultrasonography of Uterine Scar After Cesarean
ean delivery.22 Other investigators have found that
antepartum uterine scar thickness inversely corre-
lates with risk of intrapartum rupture,16 and that
antepartum assessment can predict term intrapar-
tum uterine rupture with a high degree of accura-
cy.18 The technique of antepartum evaluation of the
myometrium20 and postpartum evaluation of the
uterine scar14,19 have been described. Our study was
designed to determine if uterine closure technique
has an effect on subsequent measurement of the
uterine scar by ultrasonography.
Initial reports with one- compared with two-layer
closures focused on intraoperative and immediate
postoperative outcomes and found them to be equiv-
alent.9 A follow-up study found equivalent outcomes
in the subset of women who had a subsequent preg-
nancy and a trial of labor.12 Durnwald and Mercer10
performed a retrospective analysis of women with a
prior primary cesarean delivery. No difference was
found in rates of uterine rupture although there was
an increase in “uterine windows” at cesarean delivery
in women with a prior one-layer closure. Bujold et al13
performed a chart review of women undergoing a
trial of labor at their institution with a history of a
prior cesarean delivery. A significant increase in the
odds ratio for uterine rupture was seen in women with
a prior single-layer closure. These studies provide
important information but nonetheless are limited by
their retrospective design and unknown confounders
affecting the decisions for initial closure and subse-
quent trials of labor,10,12,13 the interpregnancy interval
on healing, and recent changes in practice patterns.13
Additionally, confounders such as operator technique
and other intraoperative factors could not be taken
into account. In contrast, we randomized allocation to
scar closure and evaluated the effect postoperatively.
Confounding variables were thus minimized by
randomization.
In the context of prior studies and our current
understanding of the relationship between scar thick-
ness and wound strength, our data suggest that it may
not matter which closure type is used at the time of
closure of a low-transverse uterine incision after ce-
sarean delivery. Further work is needed to determine
if our findings of equivalent scar thickness persist and
whether the postoperative scar thickness is predictive
of future uterine disruption.
Post hoc sample size calculations were performed
to determine the number of patients needed to
achieve statistical significance for the differences we
observed in our trial. We used the same parameters
used in the sample size calculation for this study
(power⫽80%, ␣⫽0.05). Total sample sizes (both one-
OBSTETRICS & GYNECOLOGY
and two-layer groups) varied from 1,696 patients for
the 2-week measurements to 9,522 patients for the
48-hour measurements.
Although our sample size was small, significant
results were obtained regarding the thickness of the
scar over the study interval. No significant differences
were seen between closure groups, but post hoc
power analysis revealed that large sample sizes would
need to be obtained to show significant differences
between closure types. It is unclear how long the
uterus takes to complete its remodeling, and it is
possible that significant differences between closure
types could appear at longer time intervals. A prior
study using magnetic resonance imaging suggests that
the remodeling may not be complete up to 6 months
after surgery.24 In our study, the closure groups ap-
peared to follow the same path in the change in
thickness over the follow-up interval, and it is unlikely
that differences would appear between closure types
at a later time point. Additional studies focused on the
correlation between closure technique, scar thickness,
the interpregnancy interval, and future long-term
obstetric performance are warranted.
In conclusion, it is possible to evaluate, in a
longitudinal fashion, the uterine scar by ultrasonogra-
phy in the postoperative period. Significant variation
was seen over time in the scar thickness, but this was
unrelated to uterine closure type. This study provides
a longitudinal description of myometrial wound re-
modeling using ultrasonography during the first 6
weeks post partum and establishes the effect of uterine
closure on myometrial scar morphology. Our obser-
vations enhance myometrial wound healing knowl-
edge and may open novel areas of investigation for
potential therapeutic intervention in humans to re-
duce the risk of rupture during trial of labor after prior
cesarean delivery.
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Ultrasonography of Uterine Scar After Cesarean 813