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Complications of cesarean delivery in the massively obese parturient

Published:August 05, 2010DOI:https://doi.org/10.1016/j.ajog.2010.06.049

      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 retrospective study of massively obese women (body mass index, ≥50 kg/m2) undergoing cesarean delivery. Bivariable and multivariable analyses 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 hospital 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 ≥50 kg/m2 have a much greater risk for cesarean wound complications than previously reported. Avoidance of subcutaneous drains and increased use of transverse abdominal wall incisions should be considered in massively obese parturients to reduce operative morbidity.

      Key words

      The rate of cesarean morbidity in massively obese women is unknown 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.
      • Sturn R.
      Increases in clinically severe obesity in the United States, 1986-2000.
      We previously reported that the prevalence of pregnant women with a BMI of 50 kg/m2 or more delivering at our institution is 1 in 35, and the rate of cesarean delivery in this population is approximately 60%.

      Alanis MC, Goodnight WH, Hill EG, Robinson CJ, Villers MS, Johnson DD. Maternal super-obesity (body mass index ≥ 50) and adverse pregnancy outcomes. Acta Obstet Gynecol Scand 89:924-30.

      For Editors' Commentary, see Table of Contents
      Obesity is a well-recognized risk factor for the development of a wound complication or infection after cesarean delivery.
      • Robinson H.E.
      • O'Connell C.M.
      • Joseph K.S.
      • Lynne McLeod N.
      Maternal outcomes in pregnancies complicated by obesity.
      • Myles T.D.
      • Gooch J.
      • Santolaya J.
      Obesity as an independent risk factor for infectious morbidity in patients who undergo cesarean delivery.
      • Tran T.S.
      • Jamulitrat S.
      • Chongsuvivatwong V.
      • Geater A.
      Risk factors for postcesarean surgical site infection.
      • Kabiru W.
      • Raynor B.D.
      Obstetric outcomes associated with increase in BMI category during pregnancy.
      • Schneid-Kofman N.
      • Sheiner E.
      • Levy A.
      • Holcberg G.
      Risk factors for wound infection following cesarean deliveries.
      • Cetin A.
      • Cetin M.
      Superficial wound disruption after cesarean delivery: effect of the depth and closure of subcutaneous tissue.
      • Vermillion S.T.
      • Lamoutte C.
      • Soper D.E.
      • Verdeja A.
      Wound infection after cesarean: effect of subcutaneous tissue thickness.
      Antibiotic prophylaxis for laboring and nonlaboring women and suture closure of the subcutaneous space are techniques that have been shown to reduce the incidence of wound disruption in metaanalyses of randomized controlled trials.
      • Smaill F.
      • Gyte G.M.L.
      Antibiotic prophylaxis for cesarean section.
      • Chelmow D.
      • Rodriguez E.J.
      • Sabatini M.M.
      Suture closure of subcutaneous fat and wound disruption after cesarean delivery: a meta-analysis.
      Vertical abdominal incisions and closed suction subcutaneous drains are commonly used to reduce postoperative wound complications for obese patients undergoing cesarean delivery. Evidence suggests, however, that these 2 practices have a negligible or even negative impact on the incidence of wound complications.
      • Hellums E.K.
      • Lin M.G.
      • Ramsey P.S.
      Prophylactic subcutaneous drainage for prevention of wound complications after cesarean delivery—a metaanlysis.
      • Wall P.D.
      • Deucy E.E.
      • Glantz J.C.
      • Pressman E.K.
      Vertical skin incisions and wound complications in the obese parturient.
      Accurate estimation of wound complications heretofore has been limited by previous publications that rely on hospital discharge data, telephone survey, or mailed questionnaire.
      • Schneid-Kofman N.
      • Sheiner E.
      • Levy A.
      • Holcberg G.
      Risk factors for wound infection following cesarean deliveries.
      • Gravel-Tropper D.
      • Oxley C.
      • Memish Z.
      • Garber G.E.
      Underestimation of surgical infection rates in obstetrics and gynecology.
      • Opøien H.K.
      • Valbø A.
      • Grinde-Andersen A.
      • Walberg M.
      Post-cesarean surgical site infections according to CDC standards: rates and risk factors: a prospective study.
      • Killian C.A.
      • Graffunder E.M.
      • Vinciguerra T.J.
      • Venezia R.
      Risk factors for surgical-site infections following cesarean section.
      • Johnson A.
      • Young D.
      • Reilly J.
      Cesarean section surgical site infection surveillance.
      Therefore, the objective of this study was to determine the rate of operative complications in massively obese parturients (BMI ≥50 kg/m2) undergoing cesarean delivery. Furthermore, we sought to determine whether certain operative practices are associated with increased cesarean morbidity in these patients.

      Materials and Methods

      Patients

      The institutional review board at the Medical University of South Carolina approved this retrospective study. Data were derived from a single regional tertiary referral center between Jan. 1, 2005, and Dec. 31, 2009. All patients undergoing 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 prenatal 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 outpatient electronic medical record and electronically scanned inpatient charts. Two authors performed independent review of each electronic record, and a single author (M.C.A.) verified the findings of the data abstraction.
      Body mass index (kilograms per square meter) was calculated from maternal height and predelivery weight. Gestational age was determined by the last menstrual period or ultrasound dating, according to American College of Obstetrics and Gynecology (ACOG) recommendations.
      American College of Obstetricians and Gynecologists
      ACOG practice bulletin no. 55: management of postterm pregnancy.
      Pregestational type 1 and type 2 diabetes was determined by the patient's medical histories, and gestational diabetes was determined by abnormal diagnostic testing during pregnancy according to guidelines published by the American Diabetes Association.
      American Diabetes Association
      Diagnosis and classification of diabetes mellitus.
      Pregestational and gestational diabetes were analyzed as a single, combined variable for all analyses. Preeclampsia and chronic hypertension were determined according to guidelines published by ACOG.
      American College of Obstetricians and Gynecologists
      ACOG practice bulletin no. 33: diagnosis and management of preeclampsia and eclampsia.
      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 incisions 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. Subcutaneous closure was performed with absorbable suture in all cases, and all subcutaneous drains exited through a separate incision. Typical antibiotic prophylaxis during the study period was 1 g of cefazolin except in a small number of cases, which were due to antibiotic allergy or physician preference. During the study period, the results of a randomized controlled trial influenced a practice change in favor of preincision over postcord clamp antibiotic prophylaxis.
      • Sullivan S.A.
      • Smith T.
      • Change E.
      • Hulsey T.
      • VanDorsten J.P.
      • Soper D.
      Administration of cefazolin prior to skin incision is superior to cefazolin at cord clamp in preventing postcesarean infectious morbidity: a randomized controlled trial.
      Wound complication was defined as either a wound disruption or wound cellulitis. 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 disruptions included seroma, hematoma, abscess, and fascial dehiscence. For the purposes of this study, wound cellulitis was defined as a physician diagnosis of erythema and warmth spreading beyond the immediate area surrounding the incision and requiring treatment with antibiotics. Simple, mild erythema or induration around the wound was not considered wound cellulitis, and such cases were not counted as a wound complication. 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. Bivariable analyses with the Wilcoxon rank sum test and χ2 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 abdominal incision (vertical or transverse) on wound complication. Multivariable logistic regression analysis was used to control for confounding. Unadjusted and adjusted odds ratios with 95% confidence intervals (CIs) were reported, and P < .05 was considered statistically significant. Tests for two-way interaction between dichotomous covariates were performed using the Breslow-Day test, and the Hosmer-Lemeshow goodness-of-fit test was used to assess the fit of multivariable models. The Cochran-Armitage trend test and 1-way analysis of variance (Brown-Mood test) were used to analyze changes in practice patterns over time. Statistical analyses were performed with SAS version 9.1.3 (SAS Institute, Inc, Cary, NC).

      Results

      A total of 195 women with a BMI of 50 kg/m2 or greater underwent cesarean delivery during the study period. One woman was excluded from the analysis because of maternal death on postoperative day 0, a result of hemorrhagic complications 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 hospital for treatment, and 8 (14%) required reoperation because of a wound complication. One patient with a BMI of 109 kg/m2 experienced evisceration and required resection of necrotic fascia 10 days after cesarean delivery. All other cases of reoperation required only simple wound debridement. Only 8 of 58 (14%) wound complications were diagnosed before hospital discharge. The remaining wound complications were diagnosed either in the outpatient clinical setting (52%) or the emergency department (34%). The median postoperative day of diagnosis for all wound complications was 8.5 (interquartile range [IQR], 6–11.5 days). Overall, posthospital discharge follow-up records were available for 171 patients (88%), and patients without follow-up did not differ in terms of background or operative characteristics (data not shown).
      Women who experienced a wound complication were slightly older and had higher rates of smoking, diabetes, vertical 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 complication (Table 1). The great majority of subcutaneous drains were placed in those receiving a vertical abdominal incision (Table 2). Therefore, a stratified analysis was performed to better assess the relationship between vertical abdominal incision and wound complication.
      TABLE 1Relationship between perioperative factors and wound complication
      VariableNo wound complication (n = 136)Wound complication (n = 58)OR (95% CI)P value
      Continuous data were analyzed by Wilcoxon rank sum tests, and categorical data were analyzed by χ2 tests;
      Maternal age, y
      Continuous data listed as medians (interquartile range);
      28.0 (25–33)31.0 (26–36).04
      BMI, kg/m2
      Continuous data listed as medians (interquartile range);
      54.8 (51.5–58.4)54.7 (51.3–58.7).77
      Race/ethnicity, %
       White22.1 (30)29.3 (17).52
       Black72.8 (99)67.2 (39)
       Hispanic5.2 (7)3.5 (2)
      Payer status, %
       Private insurance21.3 (29)25.9 (15).43
       Medicaid/Medicare76.5 (104)74.1 (43)
       Self-pay2.2 (3)0 (0)
      Gestational age, wks
      Continuous data listed as medians (interquartile range);
      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 (%)
       Primary47.1 (64)51.7 (30).31
       Second34.6 (47)32.8 (19)
       Third16.9 (23)10.3 (6)
       Fourth1.5 (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).37
      Fisher's exact test;
      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
      Labor, h
      Continuous data listed as medians (interquartile range);
      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, h
      Continuous data listed as medians (interquartile range);
      11.0 (5–19)10.5 (6–16.5).92
      Chorioamnionitis, %6.6 (9)3.5 (2).38
      Fisher's exact test;
      Cesarean priority, %
       Nonurgent56.6 (77)58.6 (34).41
       Urgent27.9 (38)32.8 (19)
       Emergent15.44 (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, %
      A total of 190 patients (97.9%) received prophylactic antibiotics for cesarean delivery (67 after cord clamp);
      66.2 (90)56.9 (33)0.7 (0.36–1.27).22
      Anticoagulation, %
      Anticoagulation refers to postoperative use of unfractionated heparin or enoxaparin.
      17.0 (23)24.1 (14)1.5 (0.73–3.28).25
      BMI, body mass index; CI, confidence interval; OR, odds ratio.
      Alanis. Cesarean and massive obesity. Am J Obstet Gynecol 2010.
      a Continuous data were analyzed by Wilcoxon rank sum tests, and categorical data were analyzed by χ2 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.
      TABLE 2Relationship between abdominal incision and perioperative factors
      VariableTransverse incision (n = 90)Vertical incision (n = 104)P value
      Continuous data were analyzed by Wilcoxon rank sum tests, and categorical data were analyzed by χ2 tests;
      Maternal age, y
      Continuous data listed as medians (interquartile range);
      28.0 (24–33)31.0 (26–34).007
      Body mass index
      Continuous data listed as medians (interquartile range);
      52.8 (51.1–57.1)56.1 (51.9–59.8).002
      Race, %
       White25.6 (23)23.1 (24).76
       Black68.9 (62)73.1 (76)
       Hispanic5.6 (5)3.9 (4)
      Payer, %
       Private insurance22.2 (20)23.1 (24).17
       Medicaid/Medicare74.4 (67)76.9 (80)
       Self-pay3.3 (3)0 (0)
      Gestational age, wks
      Continuous data listed as medians (interquartile range);
      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, %
       Primary50.0 (45)47.1 (49).53
       Second35.6 (32)32.7 (34)
       Third11.1 (10)18.3 (19)
       Fourth3.3 (3)1.9 (2)
      Diabetes, %18.9 (17)39.4 (41).002
      Chronic oral steroid use, %1.1 (1)2.9 (3).63
      Fisher's exact test;
      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
      Active-phase labor, h
      Continuous data listed as medians (interquartile range);
      10.0 (5–14)7.0 (4.5–13).54
      Ruptured membranes, %41.1 (37)29.8 (31).10
      Ruptured membranes, h
      Continuous data listed as medians (interquartile range);
      11.0 (6–19)10.0 (6–18.5).74
      Chorioamnionitis, %5.6 (5)5.8 (6).95
      Fisher's exact test;
      Labor epidural use, %30.0 (27)24.0 (25).35
      Cesarean priority, %
       Nonurgent60.0 (54)54.8 (57).76
       Urgent27.8 (25)30.8 (32)
       Emergent12.2 (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, min
      Continuous data listed as medians (interquartile range);
      12.0 (9–19)16.0 (11–20).06
      Total operative time, min
      Continuous data listed as medians (interquartile range);
      58.5 (49.0–73.0)71.0 (61–90.5)< .001
      Preincision antibiotics, %
      A total of 190 patients (97.9%) received prophylactic antibiotics for cesarean delivery (67 after cord clamp).
      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
      Alanis. Cesarean and massive obesity. Am J Obstet Gynecol 2010.
      a Continuous data were analyzed by Wilcoxon rank sum tests, and categorical data were analyzed by χ2 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).
      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: maternal age, smoking, diabetes, estimated blood loss, and subcutaneous drains.
      Controlling for confounders, the model verified the independent association between subcutaneous drains and wound complication (OR, 2.24; 95% CI, 1.2–4.3) and between smoking and wound complication (OR, 2.9; 95% CI, 1.1–7.4). There were no 2-way interaction terms (Breslow Day test P > .05), and the Hosmer-Lemeshow test showed adequate fit of the model (P = .24).
      Separate analyses were performed to better characterize the association between cesarean morbidity and type of abdominal incision. Women undergoing vertical incisions were slightly heavier, older, and more likely to be diabetic. They also experienced greater operative time, blood loss, rates of vertical hysterotomy, placement of subcutaneous drains, and closure of the subcutaneous space and skin closure with staples (Table 2). Over the 5 year study period, the use of vertical abdominal incisions and subcutaneous drains declined, whereas the use of subcutaneous closure and preincision prophylactic antibiotics increased in massively obese women undergoing cesarean (Table 3). Postoperative antibiotic prophylaxis (so-called extended antibiotic prophylaxis) was used in only a small, select number of cases (n = 9), mostly including women with concurrent chorioamnionitis (n = 6).
      TABLE 3Change in practice patterns and wound complications over the study period
      Variable2005 (n = 26)2006 (n = 39)2007 (n = 43)2008 (n = 39)2009 (n = 47)P value
      Cochran-Armitage trend test unless otherwise noted;
      Primary cesarean, %46.251.348.843.651.1.95
      Vertical incision, %73.166.760.533.342.6< .001
      Classic cesarean, %26.928.237.220.521.3.33
      Operative time, min
      Operative time includes skin incision to skin repair (expressed as medians);
      64.064.062.067.065.0.85
      One-way analysis of variance using median scores (Brown-Mood test).
      Preincision antibiotics, %3.928.279.189.789.4< .001
      Subcutaneous drain, %69.256.430.223.110.6< .001
      Subcutaneous closure, %30.851.355.859.063.8.01
      Staple skin closure, %53.948.748.835.968.1.32
      Anticoagulation, %7.712.89.312.845.7< .001
      Wound complication, %50.033.320.925.627.7.07
      Wound disruption, %38.528.220.925.625.5.32
      Alanis. Cesarean and massive obesity. Am J Obstet Gynecol 2010.
      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).

      Comment

      This study demonstrates that nearly 1 in 3 massively obese women will have a significant wound complication after cesarean delivery. Neither labor nor ruptured membranes were associated with wound complications in our study population. This suggests that other factors are more important in massively obese women.
      Our results support the role of smoking cessation and the avoidance of subcutaneous drains as potential strategies to reduce the risk of a cesarean wound complication. Others have recommended closed suction drains to decrease the formation of loculated fluid in the deep subcutaneous space.
      • Hurt W.G.
      Surgical instruments and drains.
      A recent metaanalysis, however, concluded no benefit for patients undergoing cesarean, regardless of obesity or any other demographic variable.
      • Hellums E.K.
      • Lin M.G.
      • Ramsey P.S.
      Prophylactic subcutaneous drainage for prevention of wound complications after cesarean delivery—a metaanlysis.
      Results from studies performed by Loong et al
      • Loong R.L.
      • Rogers M.S.
      • Chang A.M.
      A controlled trial on wound drainage in cesarean section.
      and Cruse and Foord
      • Cruse P.J.
      • Foord R.J.
      A five-year prospective study of 23,649 surgical wounds.
      are similar to our findings of potential harm associated with subcutaneous drains at cesarean delivery.
      There are several possibilities for these observations. First, the correct placement of subcutaneous drains involves an additional incision in the abdominal wall, resulting in increased tissue damage. Second, the drain tubing provides a route by which bacteria may gain access to the subcutaneous space. Third, most cesarean deliveries are clean-contaminated operations, resulting in the drain acting as a reservoir for bacteria. However, the etiology of cesarean wound complication is likely multifactorial and not fully described by the list of variables included in our study. Other potential predictors of cesarean wound complication include methicillin-resistant Staphylococcus aureus carrier status, the use of chlorhexidine preoperative skin cleaning, and glycemic control in diabetic patients.
      • Weigett J.A.
      • Lipsky B.A.
      • Tabak Y.P.
      • Derby K.G.
      • Kim M.
      • Gupta V.
      Surgical site infections: causative pathogens and associated outcomes.
      • Darouiche R.O.
      • Wall Jr, M.J.
      • Itani K.M.
      • et al.
      Chlorhexidine-alcohol versus povidone-iodine for surgical-site antisepsis.
      • Kao L.S.
      • Meeks D.
      • Moyer V.A.
      • Lally K.P.
      Peri-operative glycaemic control regimens for preventing surgical site infections in adults.
      Our results also support the use of Pfannenstiel incisions in obese patients with a large panniculus and contradict classic teaching by veteran surgeons and obstetrical texts.
      • Morrow C.P.
      • Hernandez W.L.
      • Townsend D.E.
      • Disaia P.J.
      Pelvic celiotomy in the obese patient.
      • Landon M.B.
      Cesarean Delivery.
      • Cundiff G.W.
      • Thompson J.R.
      Anatomy, incisions, and closures.
      It has been written that transverse abdominal incisions made under the pannicular fold exist in “a warm, moist, anaerobic environment associated with impaired bacteriostasis … [that] promotes the proliferation of numerous microorganisms, producing a veritable bacteriologic cesspool.”
      • Morrow C.P.
      • Hernandez W.L.
      • Townsend D.E.
      • Disaia P.J.
      Pelvic celiotomy in the obese patient.
      However, we are unable to locate any evidence to support this popular conclusion.
      In 1978, Ahern and Goodlin
      • Ahern J.K.
      • Goodlin R.C.
      Cesarean section in the massively obese.
      first reported a case series of massively obese women undergoing cesarean with a Pfannenstiel incision, in which there were no wound complications. Wall et al
      • Wall P.D.
      • Deucy E.E.
      • Glantz J.C.
      • Pressman E.K.
      Vertical skin incisions and wound complications in the obese parturient.
      found a higher rate of cesarean wound complications in severely obese women receiving vertical abdominal incisions compared with transverse incisions. However, this study was limited by a small sample size (26 women with vertical abdominal incisions) and a less obese study population (mean, 41.5).
      Transverse abdominal incisions are less painful and allow for earlier mobilization and decreased pulmonary complications.
      • Grantcharov T.P.
      • Rosenberg J.
      Vertical compared to transverse incisions in abdominal surgery.
      Furthermore, vertical abdominal incisions were associated with vertical hysterotomy in our study, usually a result of inadequate access to the lower uterine segment. When the incision extends into the contractile portion of the uterus, a vertical hysterotomy has a profound impact on future pregnancy.
      • Chauhan S.P.
      • Magann E.F.
      • Wiggs C.D.
      • Barrilleaux P.S.
      • Martin Jr, J.N.
      Pregnancy after classic cesarean delivery.
      Therefore, it is important to incorporate practices, like transverse abdominal incisions, that facilitate low uterine incisions.
      Although a Pfannenstiel incision can be challenging in obese patients with an overhanging panniculus, it is usually feasible in all but the most obese women. We typically use Montgomery straps applied to the upper abdomen and tied to the operative bed rail to retract the panniculus cephalad. We have not had difficulty ventilating such patients.
      Our data demonstrate that the accurate capture of cesarean wound complications requires reliable follow-up after hospital discharge. Previous publications 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 physical examination, diagnosis, and treatment by a physician, thus ensuring the accuracy of our results. Other studies support our findings that the majority of cesarean wound complications are diagnosed after hospital discharge.
      • Gravel-Tropper D.
      • Oxley C.
      • Memish Z.
      • Garber G.E.
      Underestimation of surgical infection rates in obstetrics and gynecology.
      • Hulton L.J.
      • Olmstead R.N.
      • Treston-Aurand J.
      • Craig C.P.
      Effect of post-discharge surveillance on rates of infectious complications after cesarean section.
      • Couto R.C.
      • Pedrosa T.M.
      • Nogueira J.M.
      • Gomes D.L.
      • Neto M.F.
      • Rezende N.A.
      Post-discharge surveillance and infectious rates in obstetric patients.
      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 inpatient vs outpatient diagnoses, outpatient treatment vs hospital readmission, and home-based nursing care. Perencevich et al
      • Perencevich E.N.
      • Sands K.E.
      • Cosgrove S.E.
      • Guadagnoli E.
      • Meara E.
      • Platt R.
      Health and economic impact of surgical site infections diagnosed after hospital discharge.
      recently demonstrated that for wound complications diagnosed after hospital discharge, the average total cost per person was an additional $3382 compared with those without a wound complication. Wound complications also result in increased pain, emotional stress, and decreased productivity.
      • Perencevich E.N.
      • Sands K.E.
      • Cosgrove S.E.
      • Guadagnoli E.
      • Meara E.
      • Platt R.
      Health and economic impact of surgical site infections diagnosed after hospital discharge.
      Strengths of our study include a high rate of documented follow-up, a conservative definition of wound complication, and a relatively large sample size of women with a BMI of 50 kg/m2 or greater. We avoided the inclusion of superficial wound disruptions that did not require active management or cases of uncomplicated wound erythema or induration. Therefore, our results likely reflect the true burden of cesarean wounds in massively obese patients.
      Weaknesses of our study include the following: (1) the retrospective study design, (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 incisions should be encouraged and the use of subcutaneous drains should be discouraged for massively obese women undergoing cesarean delivery. Future research involving cesarean wound outcomes should require a documented patient interview and physician's physical examination and avoid the utilization of hospital discharge codes or questionnaires for reliable capture of wound complications.

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