ArticleAJOG global reports2025
Single- vs double-layer uterine closure of the cesarean scar in niche development: the Nicest Study.
Article in AJOG global reports, 2025. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 2 papers.
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Who cites it
2 citing papers in PubMed.
- Uterine closure after cesarean delivery: surgical technique, biological rationale, and clinical implications.American journal of obstetrics and gynecology · 2026Review
- Matters arising: single-versus double-layer uterine closure at the time of cesarean delivery and risk of uterine scar niche.Archives of gynecology and obstetrics · 2025Article
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7 authors.
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Abstract
backgroundThere is an ongoing controversy regarding the optimal uterine closure technique for preventing niche development. Single- and double-layer closures have been considered comparable in terms of niche incidence after primary cesarean delivery. However, rather than simply the presence of a niche, its volume and residual myometrial thickness are the most potent factors in predicting gynecologic symptoms and subsequent pregnancy complications in women with cesarean scar defects. In addition, there is limited evidence on how uterine scars and niche sizes evolve over time.
objectiveThis study aimed to compare the residual myometrial thickness and niche characteristics between the single-layer and double-layer uterine closure techniques and to evaluate the change in uterine scar characteristics from 6 to 12 months after cesarean delivery. STUDY
designThis prospective randomized study was conducted from May 2022 to December 2024 at Hanoi Obstetrics and Gynecology Hospital. A total of 530 full-term pregnant women who underwent primary cesarean delivery were randomized into single- or double-layer, unlocked, continuous suture. The exclusion criteria included previous major uterine surgery and abnormal placenta (placenta previa or placenta accreta spectrum) in the current pregnancy. Women were invited for 2 consecutive follow-up visits within 10 days of menstruation at 6 months (n=429) and 12 months (n=381) after cesarean delivery. Transvaginal ultrasound was used to evaluate uterine ultrasound characteristics. If the niche was detected, 3-dimensional transvaginal ultrasound was applied to measure the niche volume via the Virtual Organ Computer-aided AnaLysis method. Complete-case analysis was performed to evaluate the change in uterine ultrasound characteristics between the 2 visits.
resultsOf 429 women who participated in the 6-month visit, 216 had single-layer closure, and 213 had double-layer closure. The niche incidence at the first assessment was similar for both uterine closure techniques, at 35.6% in the single-layer group and 31.9% in the double-layer group, respectively (
conclusionAlthough the niche incidence was similar between the 2 uterine closure techniques, the double-layer technique showed superior benefits, with greater residual myometrial thickness and healing ratio, lower large niche proportion, and smaller niche volume. The uterine scar characteristics were stable at 6 months after cesarean delivery, but the niche volume significantly increased over time. Future long-term follow-up research is needed to elucidate the relationship between niche size and clinical symptoms and to investigate the factors contributing to the temporal evolution of niche volume.
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