OBstetrics

Factors Associated With Lower Uterine Segment

Thickness Near Term in Women With Previous
Caesarean Section
Laurie Brub, MD, Mariko Arial, MD, Genevive Gagnon, MD, Normand Brassard, MD, MBA,
Amlie Boutin, BSc, Emmanuel Bujold, MD, MSc
Centre de recherche du Centre Hospitalier Universitaire de Qubec, Qubec QC
Department of Obstetrics and Gynecology, Faculty of Medicine, Universit Laval, Qubec QC

Abstract

Rsum

Objective: To estimate the association between potential influencing

factors and lower uterine segment (LUS) thickness at term in
women with previous Caesarean section.

Objectif: Estimer lassociation entre les facteurs dinfluence

possibles et lpaisseur du segment utrin infrieur (SUI)
terme chez les femmes ayant dj subi une csarienne.

Methods: We conducted a cohort study of women with previous

low-transverse Caesarean section undergoing ultrasonographic
measurement of LUS thickness between 35 and 38 weeks
gestation in a tertiary care centre between 2006 and 2009.
Measurements of the full LUS thickness and the myometrial
LUS thickness were performed both transabdominally and
transvaginally. The thinnest measurements for both full and
myometrial LUS thicknesses were considered dependent variables.
Non-parametric analyses, multivariate linear regression analyses,
and multivariate regression analyses were used to evaluate the
relationships between LUS thickness and the potential influencing
factors of maternal age, interdelivery interval, prior vaginal delivery,
and several characteristics of the previous Caesarean section.

Mthodes: Nous avons men une tude de cohorte auprs de

femmes ayant dj subi une csarienne transversale basse qui
se sont prtes la mesure chographique de lpaisseur du SUI
entre la 35e et la 38e semaine de gestation, au sein dun centre
de soins tertiaires entre 2006 et 2009. Les mesures de la pleine
paisseur du SUI et de lpaisseur myomtriale du SUI ont t
menes tant de faon transabdominale que transvaginale. Les
mesures les plus minces de la pleine paisseur et de lpaisseur
myomtriale du SUI ont t considres comme des variables
dpendantes. Des analyses non paramtriques, des analyses
de rgression linaire multivaries et des analyses de rgression
multivaries ont t utilises pour valuer les relations entre
lpaisseur du SUI et les facteurs dinfluence possibles que
constituent lge maternel, lintervalle interaccouchement, les
antcdents daccouchement vaginal et plusieurs caractristiques
de la csarienne prcdente.

Results: In 377 women who underwent measurement of LUS

thickness, labour before previous Caesarean section was the
only characteristic associated with a greater full LUS thickness
(an additional 0.9mm; 95% CI 0.5 to 1.2mm) in multivariate
linear regression analysis. Labour before previous Caesarean
section (0.5mm; 95% CI 0.2 to 0.7mm) and the use of synthetic
sutures (as opposed to catgut sutures) for the closure of the
previous hysterotomy incision (0.3mm; 95% CI 0.02 to 0.5mm)
were the only two variables significantly associated with a thicker
myometrial LUS. In multivariate regression analysis, three
factors were predictive of a full LUS thickness of >2.3mm: the
presence of labour, a recurrent indication for Caesarean section,
and the use of synthetic sutures for hysterotomy closure at
previous Caesarean section (P <0.05).
Conclusion: Labour at the time of previous Caesarean section is
associated with a thicker LUS near term in the subsequent
pregnancy. The use of synthetic sutures for hysterotomy closure
is another factor potentially associated with a thicker LUS.

Key Words: Pregnancy, ultrasound, vaginal birth after Caesarean,

uterine rupture, hysterotomy
Competing Interests: None declared.
Received on August 23, 2010

Rsultats: Chez 377femmes qui se sont prtes la mesure de

lpaisseur du SUI, le travail avant la csarienne prcdente
tait la seule caractristique associe une hausse de la pleine
paisseur du SUI (0,9mm de plus; IC 95%, 0,5 1,2mm) dans
le cadre de lanalyse de rgression linaire multivarie.
Le travail avant la csarienne prcdente (0,5mm; IC 95%,
0,2 0,7mm) et lutilisation de sutures synthtiques (par
opposition aux sutures de catgut) pour la fermeture de lincision
dhystrotomie prcdente (0,3mm; IC 95%, 0,02 0,5mm)
taient les deux seules variables prsenter une association
significative avec un SUI myomtrial plus pais. Dans le cadre de
lanalyse de rgression multivarie, trois facteurs permettaient de
prdire une pleine paisseur du SUI de >2,3mm: la prsence
de travail, une indication rcurrente de recours la csarienne
et lutilisation de sutures synthtiques pour la fermeture de
lhystrotomie au cours de la csarienne prcdente (P < 0,05).
Conclusion: Le travail au moment de la csarienne prcdente
est associ un SUI plus pais prs du terme au cours de la
grossesse subsquente. Lutilisation de sutures synthtiques
pour la fermeture de lhystrotomie constitue un autre facteur
potentiellement associ un SUI plus pais.

Accepted on October 5, 2010

J Obstet Gynaecol Can 2011;33(6):581587

JUNE JOGC JUIN 2011 l 581

OBstetrics

INTRODUCTION

terine rupture is one of the most catastrophic

obstetrical emergencies.1,2 Many publications suggest
that sonographic evaluation of the lower uterine segment
could predict uterine scar defects, including uterine rupture,
in women with a previous Caesarean section.315 Moreover,
several clinical factors influencing the risk of uterine
rupture and the success of a trial of vaginal birth after
Caesarean section have been identified and are considered
in the management of labour and delivery in women with a
previous CS.1623 Despite the demonstration that the risk of
a scar defect is inversely correlated with LUS thickness, the
factors that may influence the LUS thickness itself have not
been well described; nevertheless, a recent study by Jastrow
et al. found that labour at previous CS was associated with
an increase in LUS thickness in a subsequent pregnancy.24
The objective of this study was to determine maternal and
obstetrical factors associated with LUS thickness in women
with a previous low-transverse Caesarean section.
METHODS

We conducted a retrospective cohort study evaluating

the LUS thickness measurement in women presenting
between 35 and 38 weeks gestation at Centre Hospitalier
Universitaire de Qubec between November 2006 and
June 2009. All women with a singleton pregnancy, one or
two previous low-transverse Caesarean sections, and no
contraindication to vaginal delivery, who delivered at our
centre, were included. A standard protocol for evaluating
the LUS thickness had been developed, and the technique of
measurement had been taught to all ultrasound technicians
in our centre before the initiation of LUS measurement
in November 2006.4 During the study period, LUS
measurements were performed both transabdominally and
transvaginally (when possible) by ultrasound technicians
supervised by two maternal-fetal medicine specialists (EB,
NB). The maternal-fetal medicine specialists repeated
at least one of the two examinations (transabdominal or
transvaginal) for validation of the measurements. The
thinnest measurement of the full LUS thickness and the
thinnest measurement of the myometrial layer thickness

ABBREVIATIONS
IQ

interquartile

LUS

lower uterine segment

TOL

trial of labour

VBAC vaginal birth after Caesarean section

582 l JUNE JOGC JUIN 2011

were reported in millimetres and were used for clinical

recommendations based on previous publications.4,5 In our
local protocol, it was required that the image be magnified
such that movement of the calipers produced a 0.1mm
change in the measurement. The calipers were placed
so that the inner edge merged with the limit line of the
thickness being measured, which was perpendicular to the
measured wall. The observers (technicians and maternal
fetal medicine specialists) were usually blinded to the
patients risk factors at the time of LUS measurement. The
women were counselled that a full LUS thickness <2mm
was considered to be associated with a higher risk for
uterine rupture than that in the general population, that
a thickness of between 2mm and 3mm was considered
to be associated with approximately the same risk, and a
thickness of >3mm was considered to be associated with
a lower risk.4 An elective repeat Caesarean section was
recommended to all women with a full LUS thickness of
<2mm.
Following a review of the literature, maternal and obstetrical
factors associated with LUS thickness were identified.
These were maternal age, interdelivery interval, previous
vaginal delivery, previous VBAC, the number of previous
Caesarean sections, and characteristics of the previous
Caesarean sections, including indication (recurrent or
not), gestational age (preterm or not), labour and cervical
status, type of closure (single- vs. double-layer) and type of
suture (catgut vs. synthetic) at previous hysterotomy, birth
weight, and chorioamnionitis with or without postpartum
endometritis. Interdelivery interval was defined as the
number of months between the previous Caesarean section
and the expected date of delivery of the current pregnancy.
A recurrent indication for Caesarean section was defined as
failure to progress in labour, cephalopelvic disproportion,
or both. Labour and cervical status at previous Caesarean
section was categorized as no labour, latent phase (4cm
of cervical dilatation), or active phase (>4cm of cervical
dilatation). Birth weight was categorized as <2500g, 2500
to 3999g, and 4000g. Characteristics of the current
pregnancy and delivery and ultrasound data were also
recorded.
The association between LUS thickness and each potential
factor was evaluated using non-parametric analyses. All
factors associated with LUS thickness with a P<0.10
were included in a linear regression analysis with either
full LUS or myometrial thickness alone as a dependent
variable. Subsequently, a multivariable regression analysis
using a backwards stepwise approach was performed for
factors associated with a full LUS thickness <2.3mm as
the dependent variable, based on our previous findings.4

Factors Associated With Lower Uterine Segment Thickness Near Term in Women With Previous Caesarean Section

Associations between potential influencing factors and lower uterine

Factor

Full LUS thickness, mm

Maternal age at delivery, years

< 30
130
30 to 34
176
35
71
Pre-gestational BMI (kg/m2, N = 230)
< 25
120
25 to 29
83
30 to 34
47
35
27
Unknown
100
Gestational diabetes
No
359
Yes
18
Chorioamnionitis or endometritis at prior CS
Yes
18
No
221
Unknown
138
Gestational age at examination, weeks
35 to 36
300
37 to 38
77
Prior vaginal delivery
Yes
52
No
325
Previous CS for recurrent indication
No
234
Yes
134
Unknown
9
Labour at previous CS (maximal cervical dilatation)
No labour
162
Latent phase (< 4 cm)
43
Active phase ( 4 cm)
145
Labour (unspecified)
27
Interdelivery interval, months
< 18
29
18
345
Unknown
3
Type of uterine closure at previous CS
Single layer
136
Double layer
163
Unknown
77
Type of suture for previous uterine closure
Chromic catgut
129
Synthetic
138
Unknown
110
Birth weight at previous CS, grams
< 2500
35
2500 to 3999
272
4000
38
Unknown
32
Observer
MD no. 1
137
MD no. 2
100
Unspecified
140

Myometrial thickness, mm

0.22
3.5 (2.7 to 4.6)

1.6 (1.0 to 2.1)

3.4 (2.6 to 4.4)

1.5 (1.0 to 2.0)

3.1 (2.3 to 4.0)

P
0.43

1.3 (0.8 to 2.1)

0.12

0.33

3.1 (2.3 to 4.0)

1.4 (0.9 to 1.9)

3.4 (2.6 to 4.6)

1.5 (1.0 to 2.1)

3.3 (2.9 to 4.2)

1.5 (1.1 to 2.1)

3.8 (3.0 to 5.4)

1.5 (1.2 to 2.0)

3.5 (2.6 to 4.6)

1.6 (0.9 to 2.4)

0.08

3.4 (2.6 to 4.5)

0.12
1.5 (1.0 to 2.1)

2.9 (2.1 to 3.8)

1.6 (0.6 to 1.7)

0.07

0.03

4.3 (2.3 to 5.6)

2.0 (1.4 to 2.6)

3.2 (2.4 to 4.2)

1.4 (0.9 to 2.0)

3.4 (2.8 to 4.4)

1.5 (1.0 to 2.0)

0.40

3.4 (2.6 to 4.5)

0.01
1.5 (1.0 to 2.1)

3.3 (2.5 to 4.0)

1.3 (0.9 to 1.7)

0.37

3.3 (2.3 to 4.0)

0.45
1.5 (0.8 to 1.9)

3.3 (2.6 to 4.5)

1.5 (1.0 to 2.1)

<0.001

<0.001

3.0 (2.3 to 3.9)

1.3 (0.9 to 1.8)

3.8 (3.0 to 4.9)

1.8 (1.2 to 2.5)

3.6 (3.2 to 5.7)

1.2 (1.1 to 2.9)

<0.001

<0.001

2.9 (2.2 to 3.9)

1.2 (0.8 to 1.7)

3.3 (2.6 to 4.2)

1.5 (1.0 to 2.1)

3.8 (3.0 to 4.8)

1.7 (1.2 to 2.5)

3.5 (2.8 to 6.0)

1.6 (0.9 to 2.5)

0.26

0.40

3.1 (2.3 to 4.0)

1.4 (0.8 to 1.8)

3.3 (2.6 to 4.4)

1.5 (1.0 to 2.1)

3.9 (3.5 to 6.8)

2.0 (1.0 to 2.6)

0.59

0.21

3.3 (2.6 to 4.2)

1.4 (1.0 to 1.9)

3.4 (2.6 to 4.5)

1.6 (1.0 to 2.2)

3.4 (2.6 to 4.8)

1.4 (0.9 to 2.1)

0.07

0.04

3.1 (2.3 to 3.9)

1.4 (0.9 to 1.9)

3.5 (2.6 to 4.5)

1.6 (1.1 to 2.2)

3.4 (2.7 to 4.7)

1.5 (1.0 to 2.1)

0.049

0.09

3.1 (2.4 to 4.5)

1.4 (0.9 to 2.2)

3.3 (2.5 to 4.4)

1.5 (0.9 to 2.1)

3.9 (3.2 to 4.9)

1.8 (1.3 to 2.4)

3.3 (2.3 to 3.9)

1.3 (0.8 to 1.8)

0.34

0.43

3.2 (2.4 to 4.3)

1.5 (1.0 to 2.1)

3.5 (2.7 to 4.8)

1.7 (0.9 to 2.2)

3.3 (2.6 to 4.3)

1.4 (0.9 to 2.0)

JUNE JOGC JUIN 2011 l 583

OBstetrics

Full LUS thickness (mm) according to cervical dilatation (cm) for women in labour at
the time of the previous Caesarean section (N = 188) Each dot represents one patient. The
triangles represent women who had a CS for a recurrent indication, with a dotted fit line of the
means. The circles represent women who had a CS for a non-recurrent indication, with a fit
line of the means.

Spearmans correlation analyses were performed between

cervical dilatation at the time of previous Caesarean section
and the full LUS thickness for women who previously
underwent CS in labour. Statistical analyses were performed
with SPSS version 13.0 (SPSS Inc., Chicago IL). P values
<0.05 were considered significant.
RESULTS

During the study period 377 women underwent measurement

of LUS thickness and delivered in our centre. The median
gestational age at the time of sonographic evaluation
was 36 completed weeks (IQ range 35 to 36 weeks). LUS
thickness was measured abdominally in 214 women (57%)
and transvaginally in 351 (93%); 188 women (50%) were
evaluated using both approaches. Women who had either
only a transabdominal or only a transvaginal assessment
were not statistically different from those who had both
assessments in terms of maternal age, gestational age, BMI,
presence or absence of labour at the previous CS, or full
or myometrial LUS thickness measurement. The median full
LUS thickness in the entire cohort was 3.3mm (IQ range
584 l JUNE JOGC JUIN 2011

2.6 to 4.4mm), and the median measurement of myometrial

thickness alone was 1.5mm (IQ range 1.0 to 2.1mm).
We found three factors to be associated with a greater full
LUS thickness: the presence of labour, a recurrent indication
for CS, and fetal macrosomia at previous CS (Table). Five
factors were shown to be associated with greater myometrial
thickness: the presence of labour, a recurrent indication
for CS, chorioamnionitis (or postpartum endometritis)
at the previous CS, an early gestational age at LUS
ultrasonographic evaluation, and use of synthetic suture
for previous closure of the LUS (Table). Only previous
Caesarean section in labour remained significant in the final
model for the prediction of full LUS measurement and
was associated with an additional 0.9mm (95% CI 0.5 to
1.2mm). Using myometrial LUS thickness alone, the
presence of labour and the use of synthetic sutures for
the closure of the previous hysterotomy were the only two
significant variables associated with a thick myometrial
LUS (providing an additional 0.5mm [95% CI 0.2 to
0.7mm] and 0.3mm [95% CI 0.02 to 0.5mm], respectively).

Factors Associated With Lower Uterine Segment Thickness Near Term in Women With Previous Caesarean Section

In multivariate regression analysis, three factors remained

associated with a full LUS thickness of <2.3mm: the
absence of labour (OR 2.0; 95% CI 1.04 to 3.7), a nonrecurrent indication at the previous Caesarean section
(OR 2.5; 95% CI 1.1 to 5.4), and use of catgut sutures
(OR 2.2; 95% CI 1.1 to 4.4).
The relationship between LUS thickness and cervical
dilatation at the time of previous Caesarean section in
women who were in labour at the time of CS is shown
in the Figure. A significant direct correlation was found
between the two variables only in women with a previous
CS for a non-recurrent indication (solid line).
Of note, 161 women (43%) had a trial of labour, with 116
(72%) of them achieving successful VBAC. As expected,
women who underwent a TOL had a greater median full
LUS thickness than women who planned an elective repeat
CS (3.6mm [IQ range 2.9 to 4.6mm] vs. 3.0mm [IQ range
2.2 to 4.2mm]). Only one uterine rupture (0.6%) occurred.7
The full LUS thickness of this patient was measured
at 3.6mm and the uterine rupture occurred after labour
was induced with high doses of oxytocin (24 mU/min) in
the presence of an unfavourable cervix and dystocia. No
rupture was observed in patients who had a spontaneous
labour (0/116).
Among women who had an elective CS, the rate of
dehiscence reported by the surgeon was 9.3% (20/214).
The rate of dehiscence was 13% (9/69) in women with a
full LUS <2.3mm and 8% (11/145) in women with a full
LUS 2.3mm (P = 0.20). In this subgroup, the median full
LUS thickness in women with an intraoperative diagnosis of
dehiscence was 2.7mm (IQ range 1.9 to 3.9mm) and the
median LUS thickness in women without this diagnosis was
3.1mm (IQ range 2.2 to 4.2mm) (P = 0.10). Among the
women who had a TOL and finally underwent CS, only three
had a diagnosis of asymptomatic uterine scar dehiscence. In
this subgroup, the median full LUS thickness in women with
an intraoperative diagnosis of dehiscence was 3.9mm (IQ
range 3.1 to 4.6mm) and the median LUS thickness in women
without this diagnosis was 3.8mm (IQ range 2.9 to 4.7mm)
(P = 0.90). In the subgroup of women who underwent a
TOL, we found no difference in the incidence of uterine
rupture between women with a previous single-layer closure
(1/53; 2%) and those with a previous double-layer closure
(0/76) (Fisher exact test: P = 0.41). In the subgroup of
women who had a repeat CS, we found no difference in the
incidence of asymptomatic uterine scar dehiscence between
women with a previous single-layer closure (7/91; 8%) and
those with a previous double-layer closure (12/113; 11%)
(chi-square test: P = 0.38).

DISCUSSION

We found that labour at the time of Caesarean section

is associated with a greater LUS thickness measured by
ultrasound near term in the subsequent pregnancy. Moreover,
we observed a significant correlation between the cervical
dilatation reached during labour at the previous CS and the
LUS thickness in the subsequent pregnancy in women whose
previous CS was performed for a non-recurrent indication.
Finally, we found that the use of synthetic sutures, rather
than catgut, for the closure of the hysterotomy incision
was associated with LUS myometrial thickness and full
LUS thickness of <2.3mm. These findings are in full
agreement with Jastrow et al.,24 who recently suggested that
a previous CS performed during labour, and mainly during
the active phase of labour, is associated with a thicker LUS
in a subsequent pregnancy. These authors found that use of
synthetic sutures was associated with LUS thickness in linear
regression analysis, and with LUS thickness <3.5mm but
not <2.3mm in multivariate regression analysis, most likely
because of a type II error. While we confirmed the results
of Jastrow et al.,24 the novel finding that the type of suture
could affect both the healing of the hysterotomy incision
and the thickness of LUS in a subsequent pregnancy is of
major interest. It means that a simple change in surgical
technique could affect a womans decision regarding her
plan for delivery and may have an effect on future pregnancy
outcomes.
In a literature review, we found very few studies that
compared the use of catgut and synthetic sutures for the
closure of the hysterotomy incision. In 2002, Bujold et al.25
reported a rate of uterine rupture of 1.2% in a population
for whom catgut sutures were used in 97% of the cases.
Joura et al.26 reported no cases of uterine rupture in 186
women, including 56 who underwent a VBAC, in a centre in
which polyglactic acid sutures were used for all hysterotomy
closures. Durnwald and Mercer27 reported only four (0.7%)
uterine ruptures among 522 women who underwent a
TOL, with most of them having had a uterine closure with
polyglactin 910, a synthetic absorbable suture. Sestanovi et
al.28 found a significantly higher rate of uterine rupture in
women who had hysterotomy closure with catgut sutures
(11/302; 3.6%) than in women whose closure was with
synthetic sutures (4/1712; 0.2%,) (P<0.01). These results
suggest better healing of the uterine scar with synthetic
sutures than with catgut sutures. However, we did not find
any published randomized controlled trials comparing the
two types of sutures with follow-up to the next pregnancy,
and our recent casecontrol studies did not have the power
to evaluate such an association; only 4% of the cases and
control subjects who had a hysterotomy had closure with
JUNE JOGC JUIN 2011 l 585

OBstetrics

synthetic sutures.23 It is possible that synthetic sutures

create less tissue reaction, less inflammation, and less
infection, and therefore allow better tissue healing than
catgut sutures.
Our finding that labour at previous CS is associated with
a thicker LUS than no labour is in agreement with the
findings of Algert et al.,29 who demonstrated that labour
before the primary CS can decrease the risk of uterine
rupture in a subsequent TOL. A mechanism explaining
this association was proposed by Zimmer et al.30 in 2004.
These authors found that Caesarean sections performed
in labour, particularly those performed with advanced
cervical dilatation, involve an incision through cervical
tissue, in agreement with the physiological process of
cervical effacement during contractions. Therefore it is
possible that women who had a CS in labour with advanced
cervical dilatation had an intact LUS before labour in a
subsequent pregnancy; the Caesarean scar was actually in
the cervical tissue. These women would have a lower risk
of uterine rupture during labour or until a certain level of
cervical effacement was achieved.
Finally, we found no association between LUS thickness
and the following factors: maternal age, interdelivery
interval, and single- versus double-layer closure, despite the
fact that these factors have been associated with uterine
rupture. We suggest that they probably influence the
strength of the scar by a process independent of the LUS
thickness, such as the quality of tissue. The strength of the
scar could therefore depend on both its thickness and its
quality, which we are not able to evaluate. The only case of
uterine rupture was in a patient with a thick LUS (3.6mm).7
However, other risk factors, such as single-layer closure of
the hysterotomy incision, prolonged labour, induction of
labour with an unfavourable cervix or with prostaglandins,
short interdelivery interval, and fetal macrosomia, could
have played an important role.23,3134
Several limitations in our study should be addressed. First,
this was a retrospective study with a limited number of
patients who underwent a TOL. It is therefore difficult to
evaluate how the use of LUS measurement could influence
the rate of uterine rupture. Second, LUS measurements
were performed by two physicians assisted by several
ultrasound technicians, and we could not compare the
reproducibility of the measurements made by different
observers. However, while lack of reproducibility could
have had an influence on individual LUS measurements,
we believe that it did not affect our overall results because
the patients were referred randomly to the physicians and
technicians, who were generally blinded to the patients
data during the measurements. Finally, it is possible that
586 l JUNE JOGC JUIN 2011

surgeons who used synthetic sutures have techniques of

uterine closure that are different from those who used
catgut sutures. However, we found no effect of the number
of closure layers (single or double) on the LUS thickness,
and we were able to confirm that most uterine closures,
if not all, were performed using a continuous suturing
technique.
CONCLUSION

Labour at the time of previous Caesarean section and

possibly the use of synthetic sutures are associated with a
thicker LUS (measured by ultrasound between 35 and 38
weeks gestation) in the next pregnancy. Taking these two
factors into account could contribute to lowering the risk
of uterine rupture in women contemplating a VBAC.
ACKNOWLEDGEMENTS

Dr Emmanuel Bujold holds a Clinician Scientist Award

from the Canadian Institutes of Health Research and the
Jeanne and Jean-Louis Lvesque Perinatal Research Chair at
Universit Laval. This study was funded by the Jeanne and
Jean-Louis Lvesque Perinatal Research Chair at Universit
Laval.
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