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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 boardapproved 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.

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

RESULTS: Fifty-eight of 194 patients (30%) had a wound complication.

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.

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,

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.

he 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.1
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%.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

M ATERIALS AND M ETHODS

plication or infection after cesarean delivery.3-9 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.10,11 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.12,13
Accurate estimation of wound complications heretofore has been limited by
previous publications that rely on hospital discharge data, telephone survey, or
mailed questionnaire.7,14-17 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.

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 patients 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.

SEPTEMBER 2010 American Journal of Obstetrics & Gynecology

271.e1

SMFM Papers
Gestational age was determined by the
last menstrual period or ultrasound dating, according to American College of
Obstetrics and Gynecology (ACOG) recommendations.18 Pregestational type 1
and type 2 diabetes was determined by
the patients medical histories, and gestational diabetes was determined by abnormal diagnostic testing during pregnancy according to guidelines published
by the American Diabetes Association.19
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.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 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.21
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 disrup271.e2

www.AJOG.org
tions 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 2 test (or Fishers 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).

R ESULTS
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 com-

American Journal of Obstetrics & Gynecology SEPTEMBER 2010

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 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.
Vertical abdominal incision was not
associated with wound complication in
this stratified analysis either with (odds
ratio [OR], 3.4; 95% CI, 0.6517.20) or
without (OR, 1.4; 95% CI, 0.623.26) 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

SMFM Papers

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TABLE 1

Relationship between perioperative factors and wound complication

Variable
Maternal age, y

No wound complication
(n 136)

Wound complication
(n 58)

OR (95% CI)

P valuea

28.0 (2533)

31.0 (2636)

.04

54.8 (51.558.4)

54.7 (51.358.7)

.77

................................................................................................................................................................................................................................................................................................................................................................................

BMI, kg/m2b

................................................................................................................................................................................................................................................................................................................................................................................

Race/ethnicity, %

.......................................................................................................................................................................................................................................................................................................................................................................

White

22.1 (30)

29.3 (17)

Black

72.8 (99)

67.2 (39)

5.2 (7)

3.5 (2)

.52

.......................................................................................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................

Hispanic

................................................................................................................................................................................................................................................................................................................................................................................

Payer status, %

.......................................................................................................................................................................................................................................................................................................................................................................

Private insurance

21.3 (29)

25.9 (15)

Medicaid/Medicare

76.5 (104)

74.1 (43)

.43

.......................................................................................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................

Self-pay

2.2 (3)

0 (0)

................................................................................................................................................................................................................................................................................................................................................................................

Gestational age, wks

38.5 (3739)

.32

Smoking, %

38.0 (3539)
8.1 (11)

19.0 (11)

2.7 (1.086.54)

.03

Nullipara, %

30.2 (41)

39.7 (23)

1.5 (0.802.89)

.20

................................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................

Cesarean section, n (%)

.......................................................................................................................................................................................................................................................................................................................................................................

Primary

47.1 (64)

51.7 (30)

Second

34.6 (47)

32.8 (19)

Third

16.9 (23)

10.3 (6)

Fourth

1.5 (2)

5.2 (3)

.31

.......................................................................................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................

Diabetes, %

25.0 (34)

41.4 (24)

Chronic oral steroids, %

1.5 (2)

3.5 (2)

2.1 (1.104.06)

.02

.37c

Chronic hypertension, %

39.7 (54)

Preeclampsia, %

27.9 (38)

51.7 (30)

1.6 (0.883.02)

.12

22.4 (13)

0.7 (0.361.53)

.42

Induction of labor, %
Labor, %

28.7 (39)

32.8 (19)

1.2 (0.622.35)

.60

35.3 (48)

27.6 (16)

0.7 (0.361.37)

.29

................................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................

Labor, h

11.5 (613.5)

.44

Ruptured membranes, %

36.0 (49)

9.0 (413)

32.8 (19)

0.9 (0.451.66)

.66

Ruptured membranes, hb

11.0 (519)

10.5 (616.5)

................................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................

.92

.38c

................................................................................................................................................................................................................................................................................................................................................................................

Chorioamnionitis, %

6.6 (9)

3.5 (2)

................................................................................................................................................................................................................................................................................................................................................................................

Cesarean priority, %

.......................................................................................................................................................................................................................................................................................................................................................................

Nonurgent

56.6 (77)

58.6 (34)

Urgent

27.9 (38)

32.8 (19)

Emergent

15.44 (21)

8.6 (5)

.41

.......................................................................................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................

Operative time, %

65.0 (5482)

63.5 (5590)

.63

Vertical abdominal incision, %

47.8 (65)

67.2 (39)

2.2 (1.184.27)

.01

Subcutaneous drain, %

28.7 (39)

48.3 (28)

2.3 (1.234.38)

.009

Subcutaneous closure, %

56.6 (77)

48.3 (28)

0.7 (0.391.33)

.29

Staples skin closure, %

48.5 (66)

58.6 (34)

1.5 (0.812.80)

.19

Blood loss 1000 mL, %

30.9 (42)

46.6 (27)

1.9 (1.043.66)

.04

................................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................

Blood transfusion, %

9.6 (13)

10.3 (6)

1.1 (0.393.03)

.87

Preincision antibiotic prophylaxis, %d

66.2 (90)

56.9 (33)

0.7 (0.361.27)

.22

Anticoagulation, %e

17.0 (23)

24.1 (14)

1.5 (0.733.28)

.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 Fishers 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.

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TABLE 2

Relationship between abdominal incision and perioperative factors

Variable
Maternal age, y

Transverse incision (n 90)

Vertical incision (n 104)

28.0 (2433)

31.0 (2634)

.007

52.8 (51.157.1)

56.1 (51.959.8)

.002

P valuea

................................................................................................................................................................................................................................................................................................................................................................................

Body mass indexb

................................................................................................................................................................................................................................................................................................................................................................................

Race, %

.......................................................................................................................................................................................................................................................................................................................................................................

White

25.6 (23)

23.1 (24)

Black

68.9 (62)

73.1 (76)

5.6 (5)

3.9 (4)

.76

.......................................................................................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................

Hispanic

................................................................................................................................................................................................................................................................................................................................................................................

Payer, %

.......................................................................................................................................................................................................................................................................................................................................................................

Private insurance

22.2 (20)

23.1 (24)

Medicaid/Medicare

74.4 (67)

76.9 (80)

.17

.......................................................................................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................

Self-pay

3.3 (3)

0 (0)

................................................................................................................................................................................................................................................................................................................................................................................

Gestational age, wks

39.0 (3639)

38.0 (3639)

.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)

Second

35.6 (32)

32.7 (34)

.53

Third

11.1 (10)

18.3 (19)

Fourth

3.3 (3)

1.9 (2)

18.9 (17)

39.4 (41)

.002

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

.......................................................................................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................

Diabetes, %

................................................................................................................................................................................................................................................................................................................................................................................

Chronic oral steroid use, %

................................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................

Active-phase labor, h

10.0 (514)

7.0 (4.513)

.54

................................................................................................................................................................................................................................................................................................................................................................................

Ruptured membranes, %

41.1 (37)

29.8 (31)

.10

11.0 (619)

10.0 (618.5)

.74

................................................................................................................................................................................................................................................................................................................................................................................

Ruptured membranes, h

................................................................................................................................................................................................................................................................................................................................................................................

Chorioamnionitis, %

5.6 (5)

5.8 (6)

.95c

30.0 (27)

24.0 (25)

.35

................................................................................................................................................................................................................................................................................................................................................................................

Labor epidural use, %

................................................................................................................................................................................................................................................................................................................................................................................

Cesarean priority, %

.......................................................................................................................................................................................................................................................................................................................................................................

Nonurgent

60.0 (54)

54.8 (57)

Urgent

27.8 (25)

30.8 (32)

Emergent

.76

.......................................................................................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................

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 (919)

16.0 (1120)

................................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................

.06

................................................................................................................................................................................................................................................................................................................................................................................

Total operative time, min

.001

58.5 (49.073.0)

71.0 (6190.5)

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); Fishers exact test; A total
of 190 patients (97.9%) received prophylactic antibiotics for cesarean delivery (67 after cord clamp).
2

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TABLE 3

Change in practice patterns and wound complications over the study period
Variable

2005 (n 26)

2006 (n 39)

2007 (n 43)

2008 (n 39)

2009 (n 47)

Primary cesarean, %

46.2

51.3

48.8

43.6

51.1

Vertical incision, %

73.1

66.7

60.5

33.3

42.6

Classic cesarean, %

26.9

28.2

37.2

20.5

21.3

Operative time, min

64.0

64.0

62.0

67.0

65.0

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

Staple skin closure, %

53.9

48.7

48.8

35.9

68.1

7.7

12.8

9.3

12.8

45.7

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

P valuea
.95

................................................................................................................................................................................................................................................................................................................................................................................

.001

................................................................................................................................................................................................................................................................................................................................................................................

.33

................................................................................................................................................................................................................................................................................................................................................................................
b
c

.85

................................................................................................................................................................................................................................................................................................................................................................................

Preincision antibiotics, %

................................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................

.01

................................................................................................................................................................................................................................................................................................................................................................................

.32

................................................................................................................................................................................................................................................................................................................................................................................

Anticoagulation, %

.001

................................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................
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,

1.2 4.3) and between smoking and
wound complication (OR, 2.9; 95% CI,
1.17.4). 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).

C OMMENT
This study demonstrates that nearly 1 in
3 massively obese women will have a sig-

nificant 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.22 A recent metaanalysis, however, concluded no benefit
for patients undergoing cesarean, regardless of obesity or any other demographic variable.12 Results from studies
performed by Loong et al23 and Cruse
and Foord24 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.25-27
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.28-30 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.28 However,
we are unable to locate any evidence to
support this popular conclusion.
In 1978, Ahern and Goodlin31 first reported a case series of massively obese
women undergoing cesarean with a
Pfannenstiel incision, in which there
were no wound complications. Wall et
al13 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 ver-

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tical 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.32 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.33 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.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 inpatient 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 compared with those without a wound com271.e6

www.AJOG.org
plication. Wound complications also result in increased pain, emotional stress,
and decreased productivity.36
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 physicians physical
examination and avoid the utilization of
hospital discharge codes or questionnaires for reliable capture of wound
f
complications.
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