Cesarean Delivery in the Obese Patient

Alexander F. Burnett, MD

Division Gyn Oncology

UAMS

And she’s pregnant…And she’s in early labor…And she’s breech…And your partners are nowhere to be found…

Objectives

• 1. What is the problem?

• 2. Incision choice in the obese patient

• 3. Closure techniques

• 4. Suture material

• 5. To drain or not to drain…

The Problem:Obesity is an independent risk factor for post-operative

infectious morbidityInfectionInfection No InfectionNo Infection

Emergent c/s BMI (kg/m2) 36.6 32.2 p<.001

Obesity % 81.8 57.3p<.001

Elective c/s BMI 38.9 32.2p<.003

Obesity % 89.5 58.0 p<.04

Thickness of SubcutaneousTissue 4.1 cm 2.3 cm p=.04

Myles Ob Gyn 2002;100:959

Vermillion Ob Gyn 2000;95:923

Decisions…decisions…

Transverse vs Vertical Incisions in Abdominal Surgery

11 randomized + 7 retrospective studiesProcedures: cholecystectomy, AAA, trauma,

major laparotomy:

Significant increase in pulmonary complications, burst abdomen, incisional hernia in vertical groupNo difference in exposureTime to open : V 9.9 min

T 13.9 min p<0.05

Grantcharov Eur J Surg 2001;167:260

Vertical vs Transverse in Obese C/S

Retrospective review of 239 women undergoing primary C/S with BMI > 35

Transverse(213) Vertical(26)

Wound breakdown 2% 15% p =0.003

Wound infection 7% 19% p = 0.04

Endometritis 15% 15% p = 0.98

Chorioamnionitis 15% 3% p = 0.11

Wall Ob Gyn 2003;102:952

High Transverse vs Low Transverse

Case-control retrospective review of C/S for women >150% ideal body weight

Supraumbilical Pfannenstiel

15 54

Avg wt lbs 329 + 60 246 + 34

No difference in infectious or non-infectious complications

Houston Am J Ob Gyn 2000;182:1033

The Baby Is Out…Now What?

Is there a need for visceral peritoneum closure?549 Randomized to closure vs nonclosureClosure group had significantly more:

Febrile episodesCystitisOperative timeLength of stay

Conclusion: do not close visceral peritoneum

Nagele Am J Ob Gyn 1996;174:1366

Fascial Closure

Meta-analysis of midline abdominal closures: 15 studies/6566 patients revealedContinuous suture vs interrupted had no difference in outcomesLowest incisional hernias with slowly absorbable

and non-absorbable vs rapidly absorbableNon-absorbable had increased wound pain and

suture sinus formation over slowly absorbable

Van ‘t Riet B J Surg 2002;89:1350

Wound Healing1st phase: 1-4 d exudative phase

no wound strength2nd phase: 5-20 d proliferative phase

connective tissue repairregains 15-30% strengthdelayed if infectionperiod of hernia initiation

3rd phase: 21 d-yrs tissue remodelingregains ~ 80% strength

What About SubQ?

245 women with at least 2 cm subcut fat were randomized to closure or non-closure of Camper fascia with running 3-0 polyglycolic acid

Closure Non-closure Seroma 5.1% 17.2% p=.002 Hematoma 3.4% 1.6% p=NS Infection 6.0% 7.8% p=NS Disruption 14.5% 26.6% RR 0.5

(CI=0.3-0.9)

Naumann Ob Gyn 1995;85:412

SubQ Closure vs Drainage76 women with > 2cm subcut randomized to running 3-0

vs drain vs nothing

Suture Drain NoneInfection 7.7% 0 3.9%Separation 15.4% 4.2% 26.9%

Drain group had significantly lower rate of complications compared to non-closure group

Allaire J Repro Med 2000;45:327

SubQ Closure vs Drainage 2

964 women with subcut > 2 cm s/p C/S randomized to subcut 3-0 running vs non-closure vs 7 mm closed drain.

Suture Drain None

Wound disruption 9.9% 9.7% 8.7%

No difference in seroma/hematoma/infection rate

Magann Am J Ob Gyn 2002;186:1119

Antibiotic Prophylaxis for C/S

Cochrane review: 81 trials with 12,000 women worldwide. Contained elective C/S and non-elective C/S.

Antibiotic treated women RR:

Endometritis 0.39 (0.31-0.43)

Wound infection 0.41 (0.29-0.43)

Smaill Cochrane Library 2004;4

Take-Home Conclusions:1. Obese C/S patients at significant risk for infection and

wound disruption2. Transverse incision has fewer complications at cost of

more time to entry3. Supraumbilical transverse incision is an option4. Do not need to close the visceral peritoneum5. Close the fascia with continuous slowly absorbable

suture6. There may be a benefit to subcutaneous closure vs

drainage in the obese patient7. Antibiotics should be used in these patients to reduce

post-operative incision complications