SMFM Papers www. AJOG.

org

Complications of cesarean delivery

in the massively obese parturient
Mark C. Alanis, MD, MSCR; Margaret S. Villers, MD, MSCR; Tameeka L. Law, MD, MSCR;
Elizabeth M. Steadman, BS; Christopher J. Robinson, MD, MSCR

OBJECTIVE: The objective of the study was to determine predictors of
cesarean delivery morbidity associated with massive obesity.
STUDY DESIGN: This was an institutional review board–approved ret-
rospective study of massively obese women (body mass index, ⱖ50 kg/
m2) undergoing cesarean delivery. Bivariable and multivariable analy-
ses were used to assess the strength of association between wound
complication and various predictors.
RESULTS: Fifty-eight of 194 patients (30%) had a wound complication.
Most (90%) were wound disruptions, and 86% were diagnosed after hospi-
tal discharge (median postoperative day, 8.5; interquartile range, 6 –12).
Subcutaneous drains and smoking, but not labor or ruptured membranes,
were independently associated with wound complication after controlling
for various confounders. Vertical abdominal incisions were associated with
increased operative time, blood loss, and vertical hysterotomy.
CONCLUSION: Women with a body mass index ⱖ50 kg/m2 have a
much greater risk for cesarean wound complications than previously re-
ported. Avoidance of subcutaneous drains and increased use of trans-
verse abdominal wall incisions should be considered in massively obese
parturients to reduce operative morbidity.
Key words: cesarean delivery, obesity, superobesity, wound
complication, wound infection

Cite this article as: Alanis MC, Villers MS, Law TL, et al. Complications of cesarean delivery in the massively obese parturient. Am J Obstet Gynecol
2010;203:271.e1-7.

T he rate of cesarean morbidity in

massively obese women is un-
known despite the increasing relevance
of these patients in modern obstetrics.
The percentage of women with a body
mass index (BMI) of 50 kg/m2 or more
has increased 5-fold in the past 20 years.1
We previously reported that the preva-
lence of pregnant women with a BMI of
50 kg/m2 or more delivering at our insti-
tution is 1 in 35, and the rate of cesarean
delivery in this population is approxi-
mately 60%.2
Obesity is a well-recognized risk factor
for the development of a wound com-
From the Department of Obstetrics and
Gynecology, Medical University of South
Carolina, Charleston, SC.
Presented at the 30th Annual Meeting of the
Society for Maternal-Fetal Medicine, Chicago,
IL, Feb. 2-6, 2010.
Received March 2, 2010; revised May 7, 2010;
accepted June 17, 2010.
Reprints not available from the authors.
0002-9378/free
Published by Mosby, Inc.
doi: 10.1016/j.ajog.2010.06.049
For Editors’ Commentary,
see Table of Contents
plication or infection after cesarean de-
livery.3-9 Antibiotic prophylaxis for la-
boring and nonlaboring women and
suture closure of the subcutaneous space
are techniques that have been shown to
reduce the incidence of wound disrup-
tion in metaanalyses of randomized con-
trolled trials.10,11 Vertical abdominal in-
cisions and closed suction subcutaneous
drains are commonly used to reduce
postoperative wound complications for
obese patients undergoing cesarean de-
livery. Evidence suggests, however, that
these 2 practices have a negligible or even
negative impact on the incidence of
wound complications.12,13
Accurate estimation of wound com-
plications heretofore has been limited by
previous publications that rely on hospi-
tal discharge data, telephone survey, or
mailed questionnaire.7,14-17 Therefore,
the objective of this study was to deter-
mine the rate of operative complications
in massively obese parturients (BMI ⱖ50
kg/m2) undergoing cesarean delivery.
Furthermore, we sought to determine
whether certain operative practices are
associated with increased cesarean mor-
bidity in these patients.
M ATERIALS AND M ETHODS
Patients
The institutional review board at the
Medical University of South Carolina
approved this retrospective study. Data
were derived from a single regional ter-
tiary referral center between Jan. 1, 2005,
and Dec. 31, 2009. All patients undergo-
ing cesarean delivery between 20 and 44
weeks of gestation with a BMI of 50
kg/m2 or more were included. There
were no exclusion criteria. All cases were
performed by resident and attending
surgeons. Heights and weights were
measured at an earlier outpatient prena-
tal visit. The weight taken within 2 weeks
before delivery was used for inclusion in
the study. The patient’s recall of her last
weight within the 2 previous weeks was
used in cases of inpatient transfer.
Methods
Data were abstracted from the outpa-
tient electronic medical record and elec-
tronically scanned inpatient charts. Two
authors performed independent review
of each electronic record, and a single au-
thor (M.C.A.) verified the findings of the
data abstraction.
Body mass index (kilograms per
square meter) was calculated from ma-
ternal height and predelivery weight.

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SMFM Papers
Gestational age was determined by the
last menstrual period or ultrasound dat-
ing, according to American College of
Obstetrics and Gynecology (ACOG) rec-
ommendations.18 Pregestational type 1
and type 2 diabetes was determined by
the patient’s medical histories, and ges-
tational diabetes was determined by ab-
normal diagnostic testing during preg-
nancy according to guidelines published
by the American Diabetes Association.19
Pregestational and gestational diabetes
were analyzed as a single, combined vari-
able for all analyses. Preeclampsia and
chronic hypertension were determined
according to guidelines published by
ACOG.20
Induction of labor was defined as the
use of cervical ripening agents or uterine
contractile agents in women without
regular uterine contractions or women
with regular uterine contractions but
cervical dilation less than 3 cm. Labor
was defined as regular, painful uterine
contractions and cervical dilation of 3
cm or greater. Ruptured membranes
and chorioamnionitis were diagnosed
clinically.
Abdominal incisions were considered
vertical or transverse. Transverse inci-
sions were Pfannenstiel incisions in all
cases except 1, which was a subumbilical
transverse incision. Vertical incisions
were all paramedian or midline incisions
above or below the umbilicus. Subcuta-
neous closure was performed with ab-
sorbable suture in all cases, and all
subcutaneous drains exited through a
separate incision. Typical antibiotic pro-
phylaxis during the study period was 1 g
of cefazolin except in a small number of
cases, which were due to antibiotic al-
lergy or physician preference. During the
study period, the results of a randomized
controlled trial influenced a practice
change in favor of preincision over post-
cord clamp antibiotic prophylaxis.21
Wound complication was defined as
either a wound disruption or wound cel-
lulitis. A wound disruption was defined
as the partial or complete opening of the
deep subcutaneous space. Superficial
skin separation was not considered a
wound disruption, and these cases were
not counted as a wound complication.
Underlying causes for wound disrup-
271.e2 American Journal of Obstetrics & Gynecology SEPTEMBER 2010
tions included seroma, hematoma, ab-
scess, and fascial dehiscence. For the pur-
poses of this study, wound cellulitis was
defined as a physician diagnosis of ery-
thema and warmth spreading beyond
the immediate area surrounding the in-
cision and requiring treatment with
antibiotics. Simple, mild erythema or in-
duration around the wound was not
considered wound cellulitis, and such
cases were not counted as a wound com-
plication. Furthermore, uncomplicated
yeast infections were not considered a
wound complication.
Statistical analysis
Continuous variables were reported as
medians and interquartile ranges, and
categorical variables were reported as
column percents and frequencies. Biva-
riable analyses with the Wilcoxon rank
sum test and ␹2 test (or Fisher’s exact test
when appropriate) were performed to
assess the relationship between wound
complication and various perioperative
factors.
Stratified analysis was performed to
assess the independent effect of abdom-
inal incision (vertical or transverse) on
wound complication. Multivariable lo-
gistic regression analysis was used to
control for confounding. Unadjusted
and adjusted odds ratios with 95% con-
fidence intervals (CIs) were reported,
and P ⬍ .05 was considered statistically
significant. Tests for two-way interac-
tion between dichotomous covariates
were performed using the Breslow-Day
test, and the Hosmer-Lemeshow good-
ness-of-fit test was used to assess the fit of
multivariable models. The Cochran-Ar-
mitage trend test and 1-way analysis of
variance (Brown-Mood test) were used
to analyze changes in practice patterns
over time. Statistical analyses were per-
formed with SAS version 9.1.3 (SAS In-
stitute, Inc, Cary, NC).
R ESULTS
A total of 195 women with a BMI of 50
kg/m2 or greater underwent cesarean de-
livery during the study period. One
woman was excluded from the analysis
because of maternal death on postoper-
ative day 0, a result of hemorrhagic com-
www.AJOG.org
plications of placenta accreta. The final
study group included 194 women.
A wound complication occurred in 58
cases (30%), 52 of which (90%) were
wound disruptions. Fourteen patients
(24%) required readmission to the hos-
pital for treatment, and 8 (14%) required
reoperation because of a wound compli-
cation. One patient with a BMI of 109
kg/m2 experienced evisceration and re-
quired resection of necrotic fascia 10
days after cesarean delivery. All other
cases of reoperation required only sim-
ple wound debridement. Only 8 of 58
(14%) wound complications were diag-
nosed before hospital discharge. The re-
maining wound complications were di-
agnosed either in the outpatient clinical
setting (52%) or the emergency depart-
ment (34%). The median postoperative
day of diagnosis for all wound complica-
tions was 8.5 (interquartile range [IQR],
6 –11.5 days). Overall, posthospital dis-
charge follow-up records were available
for 171 patients (88%), and patients
without follow-up did not differ in terms
of background or operative characteris-
tics (data not shown).
Women who experienced a wound
complication were slightly older and had
higher rates of smoking, diabetes, verti-
cal abdominal incision, subcutaneous
drain, and blood loss greater than 1000
mL at their cesarean delivery (Table 1).
Neither labor nor ruptured membranes
were associated with wound complica-
tion (Table 1). The great majority of sub-
cutaneous drains were placed in those
receiving a vertical abdominal incision
(Table 2). Therefore, a stratified analysis
was performed to better assess the rela-
tionship between vertical abdominal in-
cision and wound complication.
Vertical abdominal incision was not
associated with wound complication in
this stratified analysis either with (odds
ratio [OR], 3.4; 95% CI, 0.65–17.20) or
without (OR, 1.4; 95% CI, 0.62–3.26) a
subcutaneous drain. Therefore, the final
multivariable logistic regression model
included the following predictors: ma-
ternal age, smoking, diabetes, estimated
blood loss, and subcutaneous drains.
Controlling for confounders, the
model verified the independent associa-
tion between subcutaneous drains and
www.AJOG.org SMFM Papers

TABLE 1
Relationship between perioperative factors and wound complication
No wound complication Wound complication
Variable (n ⴝ 136) (n ⴝ 58) OR (95% CI) P valuea
b
Maternal age, y 28.0 (25–33) 31.0 (26–36) — .04
................................................................................................................................................................................................................................................................................................................................................................................
BMI, kg/m2b 54.8 (51.5–58.4) 54.7 (51.3–58.7) — .77
................................................................................................................................................................................................................................................................................................................................................................................
Race/ethnicity, %
.......................................................................................................................................................................................................................................................................................................................................................................
White 22.1 (30) 29.3 (17) — .52
.......................................................................................................................................................................................................................................................................................................................................................................
Black 72.8 (99) 67.2 (39)
.......................................................................................................................................................................................................................................................................................................................................................................
Hispanic 5.2 (7) 3.5 (2)
................................................................................................................................................................................................................................................................................................................................................................................
Payer status, %
.......................................................................................................................................................................................................................................................................................................................................................................
Private insurance 21.3 (29) 25.9 (15) — .43
.......................................................................................................................................................................................................................................................................................................................................................................
Medicaid/Medicare 76.5 (104) 74.1 (43)
.......................................................................................................................................................................................................................................................................................................................................................................
Self-pay 2.2 (3) 0 (0)
................................................................................................................................................................................................................................................................................................................................................................................
b
Gestational age, wks 38.0 (35–39) 38.5 (37–39) — .32
................................................................................................................................................................................................................................................................................................................................................................................
Smoking, % 8.1 (11) 19.0 (11) 2.7 (1.08–6.54) .03
................................................................................................................................................................................................................................................................................................................................................................................
Nullipara, % 30.2 (41) 39.7 (23) 1.5 (0.80–2.89) .20
................................................................................................................................................................................................................................................................................................................................................................................
Cesarean section, n (%)
.......................................................................................................................................................................................................................................................................................................................................................................
Primary 47.1 (64) 51.7 (30) — .31
.......................................................................................................................................................................................................................................................................................................................................................................
Second 34.6 (47) 32.8 (19)
.......................................................................................................................................................................................................................................................................................................................................................................
Third 16.9 (23) 10.3 (6)
.......................................................................................................................................................................................................................................................................................................................................................................
Fourth 1.5 (2) 5.2 (3)
................................................................................................................................................................................................................................................................................................................................................................................
Diabetes, % 25.0 (34) 41.4 (24) 2.1 (1.10–4.06) .02
................................................................................................................................................................................................................................................................................................................................................................................
Chronic oral steroids, % 1.5 (2) 3.5 (2) — .37c
................................................................................................................................................................................................................................................................................................................................................................................
Chronic hypertension, % 39.7 (54) 51.7 (30) 1.6 (0.88–3.02) .12
................................................................................................................................................................................................................................................................................................................................................................................
Preeclampsia, % 27.9 (38) 22.4 (13) 0.7 (0.36–1.53) .42
................................................................................................................................................................................................................................................................................................................................................................................
Induction of labor, % 28.7 (39) 32.8 (19) 1.2 (0.62–2.35) .60
................................................................................................................................................................................................................................................................................................................................................................................
Labor, % 35.3 (48) 27.6 (16) 0.7 (0.36–1.37) .29
................................................................................................................................................................................................................................................................................................................................................................................
b
Labor, h 9.0 (4–13) 11.5 (6–13.5) — .44
................................................................................................................................................................................................................................................................................................................................................................................
Ruptured membranes, % 36.0 (49) 32.8 (19) 0.9 (0.45–1.66) .66
................................................................................................................................................................................................................................................................................................................................................................................
Ruptured membranes, hb 11.0 (5–19) 10.5 (6–16.5) — .92
................................................................................................................................................................................................................................................................................................................................................................................
Chorioamnionitis, % 6.6 (9) 3.5 (2) — .38c
................................................................................................................................................................................................................................................................................................................................................................................
Cesarean priority, %
.......................................................................................................................................................................................................................................................................................................................................................................
Nonurgent 56.6 (77) 58.6 (34) — .41
.......................................................................................................................................................................................................................................................................................................................................................................
Urgent 27.9 (38) 32.8 (19)
.......................................................................................................................................................................................................................................................................................................................................................................
Emergent 15.44 (21) 8.6 (5)
................................................................................................................................................................................................................................................................................................................................................................................
Operative time, % 65.0 (54–82) 63.5 (55–90) — .63
................................................................................................................................................................................................................................................................................................................................................................................
Vertical abdominal incision, % 47.8 (65) 67.2 (39) 2.2 (1.18–4.27) .01
................................................................................................................................................................................................................................................................................................................................................................................
Subcutaneous drain, % 28.7 (39) 48.3 (28) 2.3 (1.23–4.38) .009
................................................................................................................................................................................................................................................................................................................................................................................
Subcutaneous closure, % 56.6 (77) 48.3 (28) 0.7 (0.39–1.33) .29
................................................................................................................................................................................................................................................................................................................................................................................
Staples skin closure, % 48.5 (66) 58.6 (34) 1.5 (0.81–2.80) .19
................................................................................................................................................................................................................................................................................................................................................................................
Blood loss ⬎1000 mL, % 30.9 (42) 46.6 (27) 1.9 (1.04–3.66) .04
................................................................................................................................................................................................................................................................................................................................................................................
Blood transfusion, % 9.6 (13) 10.3 (6) 1.1 (0.39–3.03) .87
................................................................................................................................................................................................................................................................................................................................................................................
Preincision antibiotic prophylaxis, %d 66.2 (90) 56.9 (33) 0.7 (0.36–1.27) .22
................................................................................................................................................................................................................................................................................................................................................................................
Anticoagulation, %e 17.0 (23) 24.1 (14) 1.5 (0.73–3.28) .25
................................................................................................................................................................................................................................................................................................................................................................................
BMI, body mass index; CI, confidence interval; OR, odds ratio.
a
Continuous data were analyzed by Wilcoxon rank sum tests, and categorical data were analyzed by ␹2 tests; b Continuous data listed as medians (interquartile range); c Fisher’s exact test; d A total
of 190 patients (97.9%) received prophylactic antibiotics for cesarean delivery (67 after cord clamp); e Anticoagulation refers to postoperative use of unfractionated heparin or enoxaparin.
Alanis. Cesarean and massive obesity. Am J Obstet Gynecol 2010.

SEPTEMBER 2010 American Journal of Obstetrics & Gynecology 271.e3

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TABLE 2
Relationship between abdominal incision and perioperative factors
Variable Transverse incision (n ⴝ 90) Vertical incision (n ⴝ 104) P valuea
b
Maternal age, y 28.0 (24–33) 31.0 (26–34) .007
................................................................................................................................................................................................................................................................................................................................................................................
Body mass indexb 52.8 (51.1–57.1) 56.1 (51.9–59.8) .002
................................................................................................................................................................................................................................................................................................................................................................................
Race, %
.......................................................................................................................................................................................................................................................................................................................................................................
White 25.6 (23) 23.1 (24) .76
.......................................................................................................................................................................................................................................................................................................................................................................
Black 68.9 (62) 73.1 (76)
.......................................................................................................................................................................................................................................................................................................................................................................
Hispanic 5.6 (5) 3.9 (4)
................................................................................................................................................................................................................................................................................................................................................................................
Payer, %
.......................................................................................................................................................................................................................................................................................................................................................................
Private insurance 22.2 (20) 23.1 (24) .17
.......................................................................................................................................................................................................................................................................................................................................................................
Medicaid/Medicare 74.4 (67) 76.9 (80)
.......................................................................................................................................................................................................................................................................................................................................................................
Self-pay 3.3 (3) 0 (0)
................................................................................................................................................................................................................................................................................................................................................................................
b
Gestational age, wks 39.0 (36–39) 38.0 (36–39) .04
................................................................................................................................................................................................................................................................................................................................................................................
Smoking, % 12.2 (11) 10.6 (11) .72
................................................................................................................................................................................................................................................................................................................................................................................
Nullipara, % 35.6 (32) 30.7 (32) .48
................................................................................................................................................................................................................................................................................................................................................................................
Cesarean number, %
.......................................................................................................................................................................................................................................................................................................................................................................
Primary 50.0 (45) 47.1 (49) .53
.......................................................................................................................................................................................................................................................................................................................................................................
Second 35.6 (32) 32.7 (34)
.......................................................................................................................................................................................................................................................................................................................................................................
Third 11.1 (10) 18.3 (19)
.......................................................................................................................................................................................................................................................................................................................................................................
Fourth 3.3 (3) 1.9 (2)
................................................................................................................................................................................................................................................................................................................................................................................
Diabetes, % 18.9 (17) 39.4 (41) .002
................................................................................................................................................................................................................................................................................................................................................................................
Chronic oral steroid use, % 1.1 (1) 2.9 (3) .63c
................................................................................................................................................................................................................................................................................................................................................................................
Chronic hypertension, % 41.1 (37) 45.2 (47) .56
................................................................................................................................................................................................................................................................................................................................................................................
Preeclampsia, % 22.2 (20) 29.8 (31) .23
................................................................................................................................................................................................................................................................................................................................................................................
Induction of labor, % 32.2 (29) 27.9 (29) .51
................................................................................................................................................................................................................................................................................................................................................................................
Active-phase labor, % 40.0 (54) 26.9 (28) .05
................................................................................................................................................................................................................................................................................................................................................................................
b
Active-phase labor, h 10.0 (5–14) 7.0 (4.5–13) .54
................................................................................................................................................................................................................................................................................................................................................................................
Ruptured membranes, % 41.1 (37) 29.8 (31) .10
................................................................................................................................................................................................................................................................................................................................................................................
b
Ruptured membranes, h 11.0 (6–19) 10.0 (6–18.5) .74
................................................................................................................................................................................................................................................................................................................................................................................
Chorioamnionitis, % 5.6 (5) 5.8 (6) .95c
................................................................................................................................................................................................................................................................................................................................................................................
Labor epidural use, % 30.0 (27) 24.0 (25) .35
................................................................................................................................................................................................................................................................................................................................................................................
Cesarean priority, %
.......................................................................................................................................................................................................................................................................................................................................................................
Nonurgent 60.0 (54) 54.8 (57) .76
.......................................................................................................................................................................................................................................................................................................................................................................
Urgent 27.8 (25) 30.8 (32)
.......................................................................................................................................................................................................................................................................................................................................................................
Emergent 12.2 (11) 14.4 (15)
................................................................................................................................................................................................................................................................................................................................................................................
Vertical hysterotomy, % 8.9 (8) 42.3 (44) ⬍ .001
................................................................................................................................................................................................................................................................................................................................................................................
Subcutaneous drain, % 11.1 (10) 54.8 (57) ⬍ .001
................................................................................................................................................................................................................................................................................................................................................................................
Subcutaneous closure, % 37.8 (34) 68.3 (71) ⬍ .001
................................................................................................................................................................................................................................................................................................................................................................................
Staple skin closure, % 28.9 (26) 71.2 (74) ⬍ .001
................................................................................................................................................................................................................................................................................................................................................................................
Incision to delivery, minb 12.0 (9–19) 16.0 (11–20) .06
................................................................................................................................................................................................................................................................................................................................................................................
Total operative time, min b
58.5 (49.0–73.0) 71.0 (61–90.5) ⬍ .001
................................................................................................................................................................................................................................................................................................................................................................................
Preincision antibiotics, %d 72.2 (65) 55.8 (58) .02
................................................................................................................................................................................................................................................................................................................................................................................
Blood loss ⬎1000 mL, % 25.6 (23) 44.2 (46) .007
................................................................................................................................................................................................................................................................................................................................................................................
Blood transfusion, % 10.0 (9) 9.6 (10) .92
................................................................................................................................................................................................................................................................................................................................................................................
a
Continuous data were analyzed by Wilcoxon rank sum tests, and categorical data were analyzed by ␹ tests; Continuous data listed as medians (interquartile range); Fisher’s exact test; A total
2 b c d

of 190 patients (97.9%) received prophylactic antibiotics for cesarean delivery (67 after cord clamp).
Alanis. Cesarean and massive obesity. Am J Obstet Gynecol 2010.

271.e4 American Journal of Obstetrics & Gynecology SEPTEMBER 2010

www.AJOG.org SMFM Papers

TABLE 3
Change in practice patterns and wound complications over the study period
Variable 2005 (n ⴝ 26) 2006 (n ⴝ 39) 2007 (n ⴝ 43) 2008 (n ⴝ 39) 2009 (n ⴝ 47) P valuea
Primary cesarean, % 46.2 51.3 48.8 43.6 51.1 .95
................................................................................................................................................................................................................................................................................................................................................................................
Vertical incision, % 73.1 66.7 60.5 33.3 42.6 ⬍ .001
................................................................................................................................................................................................................................................................................................................................................................................
Classic cesarean, % 26.9 28.2 37.2 20.5 21.3 .33
................................................................................................................................................................................................................................................................................................................................................................................
b c
Operative time, min 64.0 64.0 62.0 67.0 65.0 .85
................................................................................................................................................................................................................................................................................................................................................................................
Preincision antibiotics, % 3.9 28.2 79.1 89.7 89.4 ⬍ .001
................................................................................................................................................................................................................................................................................................................................................................................
Subcutaneous drain, % 69.2 56.4 30.2 23.1 10.6 ⬍ .001
................................................................................................................................................................................................................................................................................................................................................................................
Subcutaneous closure, % 30.8 51.3 55.8 59.0 63.8 .01
................................................................................................................................................................................................................................................................................................................................................................................
Staple skin closure, % 53.9 48.7 48.8 35.9 68.1 .32
................................................................................................................................................................................................................................................................................................................................................................................
Anticoagulation, % 7.7 12.8 9.3 12.8 45.7 ⬍ .001
................................................................................................................................................................................................................................................................................................................................................................................
Wound complication, % 50.0 33.3 20.9 25.6 27.7 .07
................................................................................................................................................................................................................................................................................................................................................................................
Wound disruption, % 38.5 28.2 20.9 25.6 25.5 .32
................................................................................................................................................................................................................................................................................................................................................................................
a
Cochran-Armitage trend test unless otherwise noted; b Operative time includes skin incision to skin repair (expressed as medians); c One-way analysis of variance using median scores (Brown-Mood
test).
Alanis. Cesarean and massive obesity. Am J Obstet Gynecol 2010.

wound complication (OR, 2.24; 95% CI, nificant wound complication after cesar- complication is likely multifactorial and
1.2– 4.3) and between smoking and ean delivery. Neither labor nor ruptured not fully described by the list of variables
wound complication (OR, 2.9; 95% CI, membranes were associated with wound included in our study. Other potential
1.1–7.4). There were no 2-way interac- complications in our study population. predictors of cesarean wound complica-
tion terms (Breslow Day test P ⬎ .05), This suggests that other factors are more tion include methicillin-resistant Staph-
and the Hosmer-Lemeshow test showed important in massively obese women. ylococcus aureus carrier status, the use of
adequate fit of the model (P ⫽ .24). Our results support the role of smok- chlorhexidine preoperative skin clean-
Separate analyses were performed to ing cessation and the avoidance of sub- ing, and glycemic control in diabetic
better characterize the association be- cutaneous drains as potential strategies patients.25-27
tween cesarean morbidity and type of to reduce the risk of a cesarean wound Our results also support the use of
abdominal incision. Women undergo- complication. Others have recommended Pfannenstiel incisions in obese patients
ing vertical incisions were slightly closed suction drains to decrease the for- with a large panniculus and contradict
heavier, older, and more likely to be dia- mation of loculated fluid in the deep classic teaching by veteran surgeons and
betic. They also experienced greater op- subcutaneous space.22 A recent meta- obstetrical texts.28-30 It has been written
erative time, blood loss, rates of vertical analysis, however, concluded no benefit that transverse abdominal incisions
hysterotomy, placement of subcutane- for patients undergoing cesarean, re- made under the pannicular fold exist in
ous drains, and closure of the subcutane- gardless of obesity or any other demo- “a warm, moist, anaerobic environment
ous space and skin closure with staples graphic variable.12 Results from studies associated with impaired bacteriostasis . . .
(Table 2). Over the 5 year study period, performed by Loong et al23 and Cruse [that] promotes the proliferation of nu-
the use of vertical abdominal incisions and Foord24 are similar to our findings of merous microorganisms, producing a ver-
and subcutaneous drains declined, potential harm associated with subcuta- itable bacteriologic cesspool.”28 However,
whereas the use of subcutaneous closure neous drains at cesarean delivery. we are unable to locate any evidence to
and preincision prophylactic antibiotics There are several possibilities for these support this popular conclusion.
increased in massively obese women un- observations. First, the correct place- In 1978, Ahern and Goodlin31 first re-
dergoing cesarean (Table 3). Postopera- ment of subcutaneous drains involves an ported a case series of massively obese
tive antibiotic prophylaxis (so-called ex- additional incision in the abdominal women undergoing cesarean with a
tended antibiotic prophylaxis) was used wall, resulting in increased tissue dam- Pfannenstiel incision, in which there
in only a small, select number of cases (n age. Second, the drain tubing provides a were no wound complications. Wall et
⫽ 9), mostly including women with con- route by which bacteria may gain access al13 found a higher rate of cesarean
current chorioamnionitis (n ⫽ 6). to the subcutaneous space. Third, most wound complications in severely obese
cesarean deliveries are clean-contami- women receiving vertical abdominal in-
C OMMENT nated operations, resulting in the drain cisions compared with transverse inci-
This study demonstrates that nearly 1 in acting as a reservoir for bacteria. How- sions. However, this study was limited by
3 massively obese women will have a sig- ever, the etiology of cesarean wound a small sample size (26 women with ver-

SEPTEMBER 2010 American Journal of Obstetrics & Gynecology 271.e5

SMFM Papers
tical abdominal incisions) and a less
obese study population (mean, 41.5).
Transverse abdominal incisions are
less painful and allow for earlier mobili-
zation and decreased pulmonary com-
plications.32 Furthermore, vertical ab-
dominal incisions were associated with
vertical hysterotomy in our study, usu-
ally a result of inadequate access to the
lower uterine segment. When the inci-
sion extends into the contractile portion
of the uterus, a vertical hysterotomy has
a profound impact on future preg-
nancy.33 Therefore, it is important to in-
corporate practices, like transverse ab-
dominal incisions, that facilitate low
uterine incisions.
Although a Pfannenstiel incision can
be challenging in obese patients with an
overhanging panniculus, it is usually fea-
sible in all but the most obese women.
We typically use Montgomery straps ap-
plied to the upper abdomen and tied to
the operative bed rail to retract the pan-
niculus cephalad. We have not had diffi-
culty ventilating such patients.
Our data demonstrate that the accu-
rate capture of cesarean wound compli-
cations requires reliable follow-up after
hospital discharge. Previous publica-
tions relying on hospital discharge data
or posthospital discharge questionnaires
likely underestimate the incidence of
wound complication. Follow-up for our
study involved documentation of a phys-
ical examination, diagnosis, and treat-
ment by a physician, thus ensuring the
accuracy of our results. Other studies
support our findings that the majority of
cesarean wound complications are diag-
nosed after hospital discharge.14,34,35
The results of this study are timely,
considering the lack of information on
pregnant women with a BMI of 50 kg/m2
or greater and the increasing relevance of
this demographic in modern obstetrics.
The cost of wound care is complex, given
differences between estimates of inpa-
tient vs outpatient diagnoses, outpatient
treatment vs hospital readmission, and
home-based nursing care. Perencevich
et al36 recently demonstrated that for
wound complications diagnosed after
hospital discharge, the average total cost
per person was an additional $3382 com-
pared with those without a wound com-
271.e6 American Journal of Obstetrics & Gynecology SEPTEMBER 2010
plication. Wound complications also re-
sult in increased pain, emotional stress,
and decreased productivity.36
Strengths of our study include a high
rate of documented follow-up, a conser-
vative definition of wound complica-
tion, and a relatively large sample size
of women with a BMI of 50 kg/m2 or
greater. We avoided the inclusion of su-
perficial wound disruptions that did not
require active management or cases of
uncomplicated wound erythema or in-
duration. Therefore, our results likely re-
flect the true burden of cesarean wounds
in massively obese patients.
Weaknesses of our study include the
following: (1) the retrospective study de-
sign, (2) lack of postdischarge follow-up
on limited number of patients, and (3)
the lack of information on subcutaneous
depth. Retrospective studies can only
point to associations between exposures
and outcomes. Randomized controlled
trials are required to establish causation.
In summary, transverse abdominal in-
cisions should be encouraged and the use
of subcutaneous drains should be dis-
couraged for massively obese women
undergoing cesarean delivery. Future re-
search involving cesarean wound out-
comes should require a documented pa-
tient interview and physician’s physical
examination and avoid the utilization of
hospital discharge codes or question-
naires for reliable capture of wound
complications. f
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