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In this video, , associate professor, obstetrics and gynecology at University of Rochester Medical Center in Rochester, N.Y. discusses the various incision options that obstetricians are faced with when dealing with an obese patient who requires a cesarean section, and which types of incisions are associated with the least amount of complications and best patient outcomes. Following is a transcript of her comments.
Cesarean incisions in obese patients are at high risk for breakdown and infection, especially when obese patients carry their extra weight in their midsection. Wound breakdown is a significant source of morbidity and it effects 3-5% of all cesarean deliveries. And each wound complication is estimated to cost our healthcare system $4,000. For women of size, the rate of breakdown and infection approaches 25%. With almost a third to a quarter of women in this country undergoing cesarean delivery and almost a third of reproductive-age women being obese, the risks of cesarean are a significant concern for an obstetrician.
Obviously, the best way to avoid complications with a cesarean is to avoid doing a cesarean, and there are lots of data now on the best practices for labor, especially in women who struggle with weight concerns. Avoiding unnecessary induction, allowing an adequate time for early labor and not using an absolute cut-off for the length of the second stage are all great strategies. However, sometimes cesareans are necessary and can be life-saving for mom and baby. Therefore, we need to be able to perform these in the safest way possible, especially for the woman of size who is at risk for complications during her cesarean.
So, what is the best way to do a cesarean incision in a woman with significant abdominal weight? Now let's be clear: I'm not talking about cesarean incision options for women with a small amount of excess weight. I'm talking about women that are significantly overweight for their height -- BMIs of 40 and above, especially when the abdomen has a substantial pannus, or flap, present. The choices are to either use a transverse traditional or pfannenstiel incision below the pannus, a high transverse incision above the pannus, or the abdominal flap, or to do a vertical mid-line incision.
Since there isn't much data on high transverse incisions, we aren't going to be able to talk much about these. However, the theory with high transverse and vertical incisions is that the care is going to be easier -- the wound will not be below the flap of the pannus and this is going to allow for easier cleaning, improved healing, since the wound is not going to be in that warm, moist environment.
So, before we talk about which of these is the best incision, remember the best incision is the one that allows you to safely and effectively deliver that baby in a timely fashion. If there are patient-specific factors or habitus features that aren't going to allow safe delivery of the infant using one type of incision, then the incision that allows delivery is the best incision. But if you do have a choice of incisions, which one is going to give the best patient outcome?
So, let's look first at wound breakdown. There are data that suggest that vertical incisions have a higher rate of breakdown and infection than transverse incisions when you follow them out to 6 weeks postpartum, and this improved healing in transverse incisions persisted even among the highest BMI classes and for diabetic women, where infectious risk is a significant concern. There are other data that suggest that vertical incisions have a lower complication rate, but no difference in composite maternal morbidity rates when assessed at the time of hospital discharge, but these data don't address delayed complications. Both of these studies are retrospective, so there's likely significant bias in how a cesarean incision was allocated.
In addition to wound breakdown, skin incision also affects other aspects of outcomes, and vertical skin incisions are associated with increases in both postoperative pain and atelectasis -- probably from decreased mobility of the patients due to pain. So, vertical incisions are also more likely to be at the level of the fundus or upper uterus and have a higher risk of requiring a classical incision, with rates varying between 14-23%. These types of uterine incisions increase the risk for the current cesarean -- they increase blood loss, they increase wound complications, pain and stress, and they further decrease patient mobility, which can further increase the risk of DVT and other complications, postpartum. So, in addition, having a classical incision also has a significant risk for complications in subsequent pregnancies, including not allowing the option for VBAC, and necessitating late preterm birth for the next pregnancy to avoid the risk of uterine rupture.
So, when we take all these data together, if the patient's habitus will allow delivery of the baby from a transverse incision, it seems that a transverse incision below the pannus is the incision of choice for women of size. This type of incision likely decreases the risk for wound breakdown, improves recovery for the mom, as well as helps avoid a high uterine incision, and optimizes safety in the next pregnancy.