Not Closing Compared With Closing the Endometrial Layer During Cesarean Delivery: A Systematic Review and Meta-analysis.

Abstract

Objective: To perform a meta-analysis of randomized and quasi-randomized trials investigating whether endometrial closure is associated with the risk of uterine scar defects, menstrual symptoms, and associated surgical morbidity.

Data sources: The Medline, EMBASE, Cochrane Library, and ClinicalTrials.gov databases were searched until February 10, 2025. Only randomized controlled trials (RCTs) or quasi-randomized trials comparing not closing with closing the endometrium during cesarean delivery were included.

Methods of study selection: We identified 266 records in our search and two records by citation searching. Of these, 106 were considered for eligibility, and six were ultimately included in the review.

Tabulation, integration, and results: We used a random-effects meta-analysis reporting relative risk (RR) and absolute risk and 95% CIs. The risk of bias was evaluated with the Cochrane risk-of-bias tool for randomized trials 2, and findings were presented according to the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. We included six RCTs (491 women). Not including the endometrium in uterine closure reduces the risk of intermenstrual bleeding (RR 0.34, 95% CI, 0.15-0.77; two RCTs, 272 women; 6 months of follow-up; high-certainty evidence) and uterine scar defect (RR 0.53, 95% CI, 0.34-0.82; four RCTs, 392 women; I2=0.0%; 3-12 months of follow-up; high-certainty evidence). There were no differences in heavy uterine bleeding, dysmenorrhea, pelvic pain, postpartum endometritis, and residual myometrial thickness (low- to very low-certainty evidence).

Conclusion: Not suturing the endometrium reduces the risk of intermenstrual bleeding and uterine scar defect after cesarean delivery.

Systematic review registration: PROSPERO, CRD42025650124.