← Dr. Chapa’s OBGYN Clinical Pearls 
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Foreign. You know, as I've said many times before, one of the main reasons that you listen to the show is. Well, I should be. The principal reason you that you listen to the show is because we try to cover things that are fresh, hot, in print, that are clinically applicable. We've said that many times. Well, true to form, and one of the main reasons, again, why you listen to this is because you're going to be ahead of the curve. And in this case, for this episode, you're going to be two years ahead of the curve. Let me explain. So on September 10, 2023, that is almost to the date of this recording. That's two years ago, on September 10, 2023, we released an episode on hysterotomy closure at C section which was decidua free. Okay? In other words, not including the innermost layer called the decidua, AKA the endometrium. Although the endometrium is in a non pregnant uterus. So really the pregnant gravid uterus doesn't have an endometrium. It has a decidua. So back on December 10, 2023, we covered Decidua free closure and we covered all the literature at that time. Now remember, this is two years ago. Now, I hate to do this, guys, and I'm really not trying to toot my own h. Oh, well, okay, maybe we are tooting our horn here. That was Michael. I said Michael put something in there about tooting your horn. That's the best he came up with. Oh my goodness, I want this to play every time I enter labor and delivery. Is that too much to ask in rounds you're like, hey, where's Chapa? Where's he at? Ah, there he is. Okay, let's stop that. Okay, so anyway, so where I've already. Where the hell am I? On December. That's right, December. On December 10, 2023, two years ago, we covered sigil free closure. My goodness, where is this all going? Good question. We are going to bring this up to date now because in September of 2025, yo, that's this month that we're recording this. All right? So remember this is two years ago from when we did that episode. Guess what is out in the Green Journal? Anyone? Anyone? A new systematic review and meta analysis. The title of which is Not Closing compared with Closing the Endometrial Layer during Cesarean Delivery. Lo and behold, two years after we covered this on our show, we have a new systematic review and meta analysis. Now let me just stop here for a minute. We can get into the details here because this is saying a lot of very helpful things and it's also not including a very important aspect of decidua free closure. And we'll discuss that after the intro. But first of all, let me read you this title again. Not Closing Compared with Closing the Endometrial Layer during Cesarean Delivery. God bless these authors. Thankful for them. But it is already one of my pet peeves is that in again a gravid uterus, otherwise known as a pregnant uterus, there is no endometrium. The endometrium is either proliferative or it is secretory as it relates to the non pregnant menstrual cycle. Once pregnancy happens, the endometrium becomes decidualized. That's why you give hyprogestins to decidualize the endometrium and it becomes a decidua. So really I would have loved it a little bit better if the title would have been Non Closing Compared with Closing the Decidual Layer during Cesarean Delivery. But I'm a little biased since that was our topic two years ago almost to the date. So once again, absolutely not meaning to blow our own horn. I really like that. So royal, so majestic. Dun dun dun dun dun dun. Oh my goodness. We're gonna cover this new systematic review and meta analysis because my other option was to start off going I told you so. But you know who likes to to be braggadocious? I told you so. So let's cover this new systematic review and meta analysis from the green journal from September 2025 to build on and to add on to our previous episode on this topic from September of 2023. Not closing compared with Closing the Endometrial Layer during Cesarean Delivery. A Systematic Review and meta Analysis. We're going to dive into it when tired of all the spin in women's health education. Yeah, so are we. This is Dr. Chapa's OB GYN no Spin podcast. All right, everyone from the 2023 episode. Let's go back in time just for a moment. You know, I covered some key points from a personal friend. We worked together. Oh my goodness. Had to be 15 years ago. His name was Emmanuel Bugeaud. You may remember him. He is out of Canada. And his then apprentice house officer was Stephanie Robert. And we've covered a lot of his data because he's done a lot of work on uterine closure. Single layer, two layer, decidua free, including the decidua full thickness. And we covered that. Let me just recap that briefly. Also, by the way, oddly enough, some months ago, somebody sent me a message to one of our social media channels and said, hey, I listened to that episode. Just FYI, my father. I think it was father. Somebody's family member. I'm sure it was father. My father was somebody that you mentioned on the show in terms of decidua free closure. So fantastic. I mean, it really is a small community and especially when the majority of the evidence seems to say the same thing, it's very reassuring and very encouraging. Okay, so let me just recap briefly what I talked about in 2023, because this new systematic review and meta analysis absolutely confirms what I told you two years ago. There's nothing new. Short answer is, unlike most things in medicine where you do a complete through and through bite of a suture through one side of a wound and then through and through on the other for a good a sturdy structural closure that does not seem to be the best for uteruses or uteri, that or gravid a time of section. In other words, if you go through and through serosa through the inner layer of the decidua and then on the other side, at least in theory, is the idea that you're bringing endometrial tissue into the incision, which can weaken the incision and or lead to scar defects like the isomocele or otherwise known as a C section niche defect that can lead to intermenstrual bleeding and some gynecological issues. Now, let me be very clear. In the past 2023 episode, you gotta go back. So we gave you all that data. We're not gonna rehash that. But if you're asking what about TOLAC and vbac? Well, none of that is really planned out. Okay. We're talking about the endometrial lining. Typically has to do with integrity of the wound. But none of that data has really panned out. When we talk about TOLAC success or uterine rupture, Just like it's complicated with single layer or two layer closure. And I've got a variety of episodes on that that you can go the archive specifically. What I'm talking about here in this episode is the endometrium, which, at least in theory, could bring endometrial glands and stroma into the uterine incision and cause what's called the niche defect. It's possible that that could lead to TOLAC uterine rupture, but the data on that is extremely cloudy. What we do know here's a clinical pearl, guys, what we do know is that niche defects are causes of gynecological issues, mainly being based on some intermenstrual spotting. Some have said pelvic pain, others have said potentially because there's a defect in the lower uterine segment in the isthmus of the uterus, potentially, maybe some infertility as it alters circulation. Okay, so the idea is, even though it does not seem to be a benefit, clearly based on the data on TOLAC success, we still want to not contribute any problems to the other side of our camp, which is in the gynecology world. Okay, so most of the data has has favored decidua free closures to try to reduce the issues of gynecological complications that can happen mainly related to the uterine scar niche defect. Okay, so back to this present day, which is September of 2025. The authors had this objective quote to perform a meta analysis of randomized and quasi randomized trials investigating whether endometrial closure is associated with the risk of uter and scar defect, menstrual symptoms, and the associated surgical morbidity. Okay, so that's what we're talking about. Does this lead to gynecological issues, and does it lead to any potential surgical complications? Great. Now, the only issue is when you do a lot of this data and remember, they're doing this based on RCTs and quasi RCTs. Really, they came up with not a lot. Okay, so the final analysis was using 6 RCTs with a total N just under 5. 6 RCTs. It's good, it's great, but it's not like we're talking, you know, a dozen or, you know, 20 or 36 RCTs.
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Now remember, I just want to as we make this new commitment in the no Spin podcast and let you know what you need to know and quickly move on. Let me tell you what they found, then we'll go through some of the details here. Okay. Quote not including the endometrium in uterine closures reduces the risk of intramenstrual bleeding with a relative risk of 0.5. So let's stop there for a minute. Okay, that's good. So we get that. If it's going to prevent intermenstrual spotting, which is a quality of life issue for a lot of women, then let's do that. But that's not all. So hold on. So let me continue, because that's not the whole sentence here. Quote not including the endometrium in uterine closure reduces the risk of intramenstrual bleeding. Yes, we just said that. And uterine scar defect with a relative risk of 0.53. All again, super helpful. Now that's great. So, okay, we can reduce intra menstrual bleeding. What else can we do? Right now we're on a win and we're going to reduce the isthmocele. All right, that's great. What else? Well, here's where it's kind of anticlimactic. There were no differences in heavy menstrual bleeding, dysmenorrhea, pelvic pain, postpartum endometritis, or residual myometral thickness. And that's based on low to very low certainty evidence. End quote. So in other words, the take home message is none of the trials found. Here it is, guys. Here's another clinical pro number two. None of the trials found that avoiding the decidua was harmful. How about that? None of them found that avoiding the decidua was harmful. On the contrary, including the decidua, increase the rate of intramenstrual bleeding and the uterine scar defect. That's the bad news. But the good news is in this study, although others have said otherwise, it didn't seem to increase the rates of dysmenorrhea, pelvic pain, postpartum endometritis or residual myometral thickness. So let's bring this back to real world. I just talked to one of our podcast family members who sent me a message. We communicated she was getting ready to do their oral boards. If you are asked, should you or should you not include the decidua at hysterotomy closure, the answer should be based on our best valuable evidence. It seems that avoiding the decidua, which actually has no structural integrity to begin with, so we shouldn't be including it in terms of adding any additional strength because it doesn't add any and that's going to shed anyway. But it seems that based on the most current evidence as of September 2025 in the green Journal, that avoiding the decidua seems to reduce some gynecological issues, which is at least intramenstrual bleeding and at least on ultrasound, what's called the isthmocele or the C section scar defect, although it doesn't seem to make a difference, at least according to the latest systematic review and meta analysis in terms of dysmenorrhea, pelvic pain or residual myometral thickness, although other studies have suggested that that is a related issue in gynecology. But the good news is, is that there is no evidence that not including it is somehow harmful. Does that make sense? So the short answer is Yes, I believe we should not include the decidua, otherwise known as the endometrium in our hysterotomy closure because number one, it doesn't add any strength, number two, it can only mess things up in terms of gynecology. And then number three, there's some controversial data whether it causes some pelvic pain or dysmenorrhea in some studies and others say no. So why don't we just avoid that to begin with? That seems to be the evidence based conclusion of the systematic review and meta analysis. According to the authors, their conclusion was not. Suturing the endometrium reduces the risk of intramenstrual bleeding and uterine scar defect after cesarean section, end quote. Nothing in there about tolac, nothing about success with a vbac. So if you're asked, does avoiding the endometrium, is that better to prevent uterine rupture? Well, we just don't have that in the data. It makes sense because you would bring endometrial or soft tissue quote unquote into the malmutrial layer. But the data is very confusing because it's so much deeper than just the layer of decidua. When we're talking about future rupture, we're talking about augmentation, polyhydramno. So the amount of fluid is a factor, the type of contractions are a factor. Whether it was there was infection present in the first C section because infection seems to potentially at least, especially if there was metritis, maybe weakened the closure, was it single layer, was it two layer? So it's way, way complicated. Way too many multifactorial influences here to say. It's just the one issue with a decidua in terms of toe lac or VBAC success and or rupture. Okay, so this is why right now there is no guidance, there's no criteria on whether you should allow a TOLAC based on how the hysterotomy was closed. We don't do that. We just do it based on where the hysterotomy was located. Does that make sense? Right, so if somebody comes in with a prior low transverse C section times one, we say let me just confirm this. Yep, low transverse C section times one seems to be no involvement of the contractile portion. Okay, so do you want to try? Because we would encourage that as long as in the non contractile portion. So it's the location, we don't say, well, was it a single layer or two layer closure? Was it decidua free I mean, you can say that, but that shouldn't be a deciding point into whether or not you would counsel a patient for or against a vbac, a TOLAC for a vbac. It's simply based on the number of incisions and the location of those incisions from the prior cesareans. Okay. Excluding of course, other transfundal surgery like a myomectomy. So what is the take home from this brand new systematic review and meta analysis from this month, September 2025 in the green Journal? Don't include the decidua. Hello. We said that two years ago. And guys, I'm not going to go into all of the studies and the quasi RCTs in breaking all this down because we covered this two years ago. I'm just going to point. You go back to archive, you can go up to the search menu and just look for decidua free closure and you can find that because it. It. We kind of covered this already. Once again, one of the perks of why you listen to this episodes to this show is because we are kind of ahead of the curve here. And I don't mean that in a braggadocious way, but it's just the truth. It's what we do. Oh, there it is again. Oh my goodness gracious. That's Michael. All right, that's just. Let's cut that out. So yeah, that's why we have this commitment to get this information off quickly when it comes out, so that when things finally do come in print or later on, somebody else prints this as a brand new finding. As we've said many times before, there is nothing new under the sun. Now, one of the things that these authors did state towards the end of this publication is something that I don't want to overlook, which is what I've already told you in terms of harm, no study, no publication showed that there was harm by avoiding the decidua at hysterectomy closure. So this is good news. So because there's potentially some issues in the gynecological world, not so much in the OB world, but in the gynecological world, it is much, much better to just avoid the inner layer of the uterus when we're doing this hysterotomy closure. Now, if you're interested on single layer versus two layer, again, I think we've got at least four episodes in the past where we've covered that. I may have covered that back in 2023 as well, but we're not going to cover that. In this one, we wanted to focus just on the inner layer of the decidua. So, podcast family, I think we've done what we're supposed to do again, relatively quick. Just want to let you know what was out in print. And again, as Michael so beautifully gave us those little trumpets, we're not trying to toot our own horn here. We're just trying to let you know the advantages of being part of our podcast family. All right, everyone, as always, we're thankful for you. We're glad you're part of our community. Now that we've done all that, let's take it home. Podcast family, we're thankful for all of us to support that you've given us throughout the years. This has been the OBGYN no Spin podcast. We'll see you on the next episode.