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Currently, data are lacking from randomized clinical trials (RCTs) regarding the optimal cesarean delivery (CD) skin incision for women with obesity. Our purpose was to evaluate the association between types of skin incision (transverse vs. vertical) and the risk of wound complications in women with morbid obesity.
We performed a multicenter cohort study of morbidly obese (BMI ≥ 40 kg/m2) women with GA ≥ 24 weeks who had primary CD. Clinical characteristics and outcomes were compared between women who had a transverse or vertical skin incision. Outcomes studied were wound complication (infection, seroma, hematoma, evisceration, or dehiscence) and a composite of maternal complications (transfusion, hysterectomy, organ injury, coagulopathy, thromboembolic event, pulmonary edema, death). Multivariable logistic regression analyses were performed.
3,200 women met study criteria (N=2,603 transverse [81.3%], N=597 vertical [18.7%]). In univariate comparisons, factors associated with vertical incision were white race, higher BMI, government insurance, diabetes, chorioamnionitis, non-lower segment hysterotomy, and emergency CD. Without adjusting for other factors, women with vertical incision were more likely to have wound complications (4.2% vs. 1.7%; p<0.001) and composite maternal complications (5.0% vs. 2.9%; p=0.02). Logistic regression analyses indicated that vertical skin incision was associated with a lower risk for wound complications (adjusted OR 0.32, 95% CI 0.17-0.62; p<0.001) but not composite maternal complications (adjusted OR 0.72, 95% CI 0.41-1.25; p=0.24).
In morbidly obese women undergoing primary CD, there is significant selection bias regarding whether a woman receives a transverse or vertical skin incision. Logistic regression analyses revealed that vertical skin incision was associated with a lower wound complication rate. Our observational data underscore the need for a RCT comparing skin incision types in this patient population.