Hi, I found your website while searching for info about double vs single layer closures during c-secs. I wanted to see if you could give me your opinion. I am 41 years old and have had 3 c-secs in the past, the last being 13 years ago.  I have a midwife that is willing to do a vbac with me.  Just yesterday we had our first visit with her and while looking through my records from my c-secs we noticed that the last 2 were done with single layer closures.  I trial labored with my first 2, having been induced probably too early, and never dilated past 5 or 6.  So consequently had 2 c-secs, then my 3rd was scheduled.  I need to research and talk to some different docs and would greatly appreciate your opinion.  Thanks.

Here's what the research has to say: a systematic review (a study that "studies studies" on a particular issue) of scar rupture reported a pooled rate of 1.4% in 16 studies comprising 1666 women. A study looking at scar rupture in women laboring after three or more cesareans found none, but there were only 89 women, way too few to have confidence that the odds with three  prior cesareans is similar to two. However, the likelihood of scar rupture is increased by some factors, notably induction or oxytocin (Pitocin or "Pit") augmentation of labor and, yes, single-layer uterine closure. The largest study reported a rate of 3% with single-layer suturing versus 0.5% with double-layer. On the other hand, it is decreased by other factors such as longer interval to next pregnancy and midwifery model care, which a study shows both decreases scar rupture rates and increases VBAC rates.

In my opinion, your best VBAC option would be midwifery-style care in a hospital prepared to handle the need for urgent cesarean 24/7. Unfortunately, the odds of your finding a hospital-based care provider willing to agree to a VBAC at all are very low, and the odds of finding one willing to be patient and supportive during labor are even lower. On the other hand, signing up for another cesarean exposes you and any future babies to the escalating risks of severe complications with the accumulation of cesarean surgeries as well as to the risks attendant on any individual surgery. (The increasing risks, as you may know, arise from increasing likelihood of placental attachment abnormalities and of dense adhesions, which can be problematic not just during cesarean surgery but in any future pelvic surgeries.) As you say, you need to see what hospital-based options may be available to you. If a hospital-based VBAC is possible, you'll have to see if its parameters are acceptable to you. If not or you have no hospital option, it's not an easy decision, and only you can decide what is best.

~ Henci

Thanks for your response. Our local hospitals that offer midwifery will only allow trial labors after 2 c-secs, not 3.  Although that's just the midwifery section.  Some of the doctors will consider it.  You just have to go in for an individual evaluation.  I will have to do that to get a consultation to see what they think. The midwife that is willing to do a home birth with me lives about 10 minutes from the hospital.  Do you think that would be sufficient if that ends up being my only choice to try a vbac?

I'm a bit confused. If you are laboring at home, it is your distance from the hospital that is at issue, not the midwife's.

~ Henci

I apologize, the midwife has a birthing area in her home and she only lives 10 min from the hospital.  We live about 30 min so we thought we might do the homebirth there.

That makes sense. Here's my analysis of the situation: There are three possibilities that would require hospital transfer:

1. Non-urgent situation such as slow labor: in this case, it wouldn't matter whether you were at home or at the midwife's house.
2. Urgent but not emergent situation:  baby not happy, symptoms that suggest possible scar rupture such as unusual pain or bleeding, or both. Being at the midwife's house would be an advantage.
3. Emergency situation: in this case, the midwife's house would be better than your house, but it is possible that it wouldn't matter how close you were to the hospital or even whether you were in the hospital itself. 

Two missing pieces are:

1. Can the hospital handle an emergent situation 24/7?
2. How good a relationship does the midwife have with the hospital staff? If she were to call and say I'm bringing a woman in who will need a cesarean stat when we arrive, would the OR and OR staff be waiting for you when you came in the door? Unfortunately, this is often not the case.

~ Henci     

Henci, my records from my past 2 c-sections show that I had first a running locked suture followed by an imbricating suture.....would this be a double layer closure?  Thanks.

I am, of course, not a clinician, but I remembered that I have Gretchen Humphries' talk on uterine closure techniques at ICAN's 2007 conference, and, yes, you have double-layer closure. (Gretchen's day job is as a veterinarian. She has performed cesarean surgeries, just not on people.) 

~ Henci