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DOI: 10.1055/s-0038-1667287
Pfannenstiel versus Vertical Skin Incision for Cesarean Delivery in Women with Class III Obesity: A Randomized Trial
Funding The trial received only internal funding from both sites.Publication History
10 April 2018
07 June 2018
Publication Date:
30 July 2018 (online)
![](https://www.thieme-connect.de/media/ajp/201901/lookinside/thumbnails/10-1055-s-0038-1667287_180185-1.jpg)
Abstract
Objective To compare Pfannenstiel versus vertical skin incision for the prevention of cesarean wound complications in morbidly obese women.
Study Design Women with body mass index ≥ 40 kg/m2 undergoing cesarean delivery (CD) were randomly allocated to Pfannenstiel or vertical skin incision. The primary outcome was a wound complication within 6 weeks. Due to a low consent rate, we limited enrollment to a defined time period for feasibility. We conducted a traditional frequentist analysis with log-binomial regression to obtain relative risks (RRs), and a Bayesian analysis to estimate the probability of treatment benefit. A priori, we decided that a ≥60% probability of treatment benefit for either incision type would be convincing evidence to pursue a larger trial.
Results A total of 648 women were approached, 228 were consented, and 91 were randomized. The primary outcome rate was 19% in the Pfannenstiel group and 21% in the vertical group (RR: 1.18; 95% confidence interval: 0.49–2.85). Bayesian analysis revealed a 59% probability that Pfannenstiel had a lower primary outcome rate.
Conclusion In the first published randomized trial to compare skin incision types for obese women undergoing CD, we were unable to demonstrate differences in clinical outcomes. Our trial suggests that a larger study would have a low probability for different findings.
Trial Registration NCT 01897376 (www.clinicaltrials.gov).
Keywords
cesarean - skin incision - Pfannenstiel - transverse - vertical - wound infection - complication - obesityCondensation
Randomized trial of cesarean skin incision type was unable to show a difference in wound complications in women with class III obesity.
Note
This study was presented in oral format at the 38th Annual Pregnancy Meeting, Society of Maternal-Fetal Medicine, Dallas, TX, January 29 to February 3, 2018.
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References
- 1 Martin JA, Hamilton BE, Osterman MJ, Curtin SC, Matthews TJ. Births: final data for 2013. Natl Vital Stat Rep 2015; 64 (01) 1-65
- 2 Poobalan AS, Aucott LS, Gurung T, Smith WC, Bhattacharya S. Obesity as an independent risk factor for elective and emergency caesarean delivery in nulliparous women--systematic review and meta-analysis of cohort studies. Obes Rev 2009; 10 (01) 28-35
- 3 Alanis MC, Villers MS, Law TL, Steadman EM, Robinson CJ. Complications of cesarean delivery in the massively obese parturient. Am J Obstet Gynecol 2010; 203 (03) 271.e1-271.e7
- 4 Perlow JH, Morgan MA, Montgomery D, Towers CV, Porto M. Perinatal outcome in pregnancy complicated by massive obesity. Am J Obstet Gynecol 1992; 167 (4 Pt 1): 958-962
- 5 Olsen MA, Butler AM, Willers DM, Devkota P, Gross GA, Fraser VJ. Risk factors for surgical site infection after low transverse cesarean section. Infect Control Hosp Epidemiol 2008; 29 (06) 477-484
- 6 McLean M, Hines R, Polinkovsky M, Stuebe A, Thorp J, Strauss R. Type of skin incision and wound complications in the obese parturient. Am J Perinatol 2012; 29 (04) 301-306
- 7 Wall PD, Deucy EE, Glantz JC, Pressman EK. Vertical skin incisions and wound complications in the obese parturient. Obstet Gynecol 2003; 102 (5 Pt 1): 952-956
- 8 Bell J, Bell S, Vahratian A, Awonuga AO. Abdominal surgical incisions and perioperative morbidity among morbidly obese women undergoing cesarean delivery. Eur J Obstet Gynecol Reprod Biol 2011; 154 (01) 16-19
- 9 Vermillion ST, Lamoutte C, Soper DE, Verdeja A. Wound infection after cesarean: effect of subcutaneous tissue thickness. Obstet Gynecol 2000; 95 (6 Pt 1): 923-926
- 10 Thornburg LL, Linder MA, Durie DE, Walker B, Pressman EK, Glantz JC. Risk factors for wound complications in morbidly obese women undergoing primary cesarean delivery. J Matern Fetal Neonatal Med 2012; 25 (09) 1544-1548
- 11 Stamilio DM, Scifres CM. Extreme obesity and postcesarean maternal complications. Obstet Gynecol 2014; 124 (2 Pt 1): 227-232
- 12 Smid MC, Kearney MS, Stamilio DM. Extreme obesity and postcesarean wound complications in the Maternal-Fetal Medicine Unit Cesarean Registry. Am J Perinatol 2015; 32 (14) 1336-1341
- 13 Takoudes TC, Weitzen S, Slocum J, Malee M. Risk of cesarean wound complications in diabetic gestations. Am J Obstet Gynecol 2004; 191 (03) 958-963
- 14 Perencevich EN, Sands KE, Cosgrove SE, Guadagnoli E, Meara E, Platt R. Health and economic impact of surgical site infections diagnosed after hospital discharge. Emerg Infect Dis 2003; 9 (02) 196-203
- 15 Flegal KM, Carroll MD, Kit BK, Ogden CL. Prevalence of obesity and trends in the distribution of body mass index among US adults, 1999-2010. JAMA 2012; 307 (05) 491-497
- 16 Springel EH, Wang XY, Sarfoh VM, Stetzer BP, Weight SA, Mercer BM. A randomized open-label controlled trial of chlorhexidine-alcohol vs povidone-iodine for cesarean antisepsis: the CAPICA trial. Am J Obstet Gynecol 2017; 217 (04) 463.e1-463.e8
- 17 Tuuli MG, Liu J, Stout MJ. , et al. A randomized trial comparing skin antiseptic agents at cesarean delivery. N Engl J Med 2016; 374 (07) 647-655
- 18 Cruse PJ, Foord R. A five-year prospective study of 23,649 surgical wounds. Arch Surg 1973; 107 (02) 206-210
- 19 Sullivan SA, Smith T, Chang E, Hulsey T, Vandorsten JP, Soper D. Administration of cefazolin prior to skin incision is superior to cefazolin at cord clamping in preventing postcesarean infectious morbidity: a randomized, controlled trial. Am J Obstet Gynecol 2007; 196 (05) 455.e1-455.e5
- 20 Witt A, Döner M, Petricevic L. , et al. Antibiotic prophylaxis before surgery vs after cord clamping in elective cesarean delivery: a double-blind, prospective, randomized, placebo-controlled trial. Arch Surg 2011; 146 (12) 1404-1409
- 21 Costantine MM, Rahman M, Ghulmiyah L. , et al. Timing of perioperative antibiotics for cesarean delivery: a metaanalysis. Am J Obstet Gynecol 2008; 199 (03) 301.e1-301.e6
- 22 Allaire AD, Fisch J, McMahon MJ. Subcutaneous drain vs. suture in obese women undergoing cesarean delivery. A prospective, randomized trial. J Reprod Med 2000; 45 (04) 327-331
- 23 Cetin A, Cetin M. Superficial wound disruption after cesarean delivery: effect of the depth and closure of subcutaneous tissue. Int J Gynaecol Obstet 1997; 57 (01) 17-21
- 24 Chelmow D, Huang E, Strohbehn K. Closure of the subcutaneous dead space and wound disruption after cesarean delivery. J Matern Fetal Neonatal Med 2002; 11 (06) 403-408
- 25 Del Valle GO, Combs P, Qualls C, Curet LB. Does closure of Camper fascia reduce the incidence of post-cesarean superficial wound disruption?. Obstet Gynecol 1992; 80 (06) 1013-1016
- 26 Magann EF, Chauhan SP, Rodts-Palenik S, Bufkin L, Martin Jr JN, Morrison JC. Subcutaneous stitch closure versus subcutaneous drain to prevent wound disruption after cesarean delivery: a randomized clinical trial. Am J Obstet Gynecol 2002; 186 (06) 1119-1123
- 27 Naumann RW, Hauth JC, Owen J, Hodgkins PM, Lincoln T. Subcutaneous tissue approximation in relation to wound disruption after cesarean delivery in obese women. Obstet Gynecol 1995; 85 (03) 412-416
- 28 Ramsey PS, White AM, Guinn DA. , et al. Subcutaneous tissue reapproximation, alone or in combination with drain, in obese women undergoing cesarean delivery. Obstet Gynecol 2005; 105 (5 Pt 1): 967-973
- 29 Ahmed B, Abu Nahia F, Abushama M. Routine cervical dilatation during elective cesarean section and its influence on maternal morbidity: a randomized controlled study. J Perinat Med 2005; 33 (06) 510-513
- 30 Tosun M, Sakinci M, Celik H. , et al. A randomized controlled study investigating the necessity of routine cervical dilatation during elective cesarean section. Arch Gynecol Obstet 2011; 284 (01) 85-89
- 31 Gungorduk K, Yıldırım G, Asıcıoğlu O, Gungorduk OC, Sudolmus S, Ark C. Efficacy of intravenous tranexamic acid in reducing blood loss after elective cesarean section: a prospective, randomized, double-blind, placebo-controlled study. Am J Perinatol 2011; 28 (03) 233-240
- 32 Liabsuetrakul T, Peeyananjarassri K. Mechanical dilatation of the cervix at non-labour caesarean section for reducing postoperative morbidity. Cochrane Database Syst Rev 2011; (11) CD008019
- 33 Scifres CM, Leighton BL, Fogertey PJ, Macones GA, Stamilio DM. Supplemental oxygen for the prevention of postcesarean infectious morbidity: a randomized controlled trial. Am J Obstet Gynecol 2011; 205 (03) 267.e1-267.e9
- 34 Gardella C, Goltra LB, Laschansky E. , et al. High-concentration supplemental perioperative oxygen to reduce the incidence of postcesarean surgical site infection: a randomized controlled trial. Obstet Gynecol 2008; 112 (03) 545-552
- 35 Houston MC, Raynor BD. Postoperative morbidity in the morbidly obese parturient woman: supraumbilical and low transverse abdominal approaches. Am J Obstet Gynecol 2000; 182 (05) 1033-1035
- 36 Committee on Obstetric Practice, the American Institute of Ultrasound in Medicine, and the Society for Maternal-Fetal Medicine. Committee Opinion No 700: methods for estimating the due date. Obstet Gynecol 2017; 129 (05) e150-e154
- 37 Surgical Site Infection (SSI) Event. Available at: https://www.cdc.gov/nhsn/pdfs/pscmanual/9pscssicurrent.pdf . Accessed May 1, 2013
- 38 Pedroza C, Han W, Truong VT, Green C, Tyson JE. Performance of informative priors skeptical of large treatment effects in clinical trials: a simulation study. Stat Methods Med Res 2018; 27 (01) 79-96
- 39 Swank ML, Wing DA, Nicolau DP, McNulty JA. Increased 3-gram cefazolin dosing for cesarean delivery prophylaxis in obese women. Am J Obstet Gynecol 2015; 213 (03) 415.e1-415.e8
- 40 Maggio L, Nicolau DP, DaCosta M, Rouse DJ, Hughes BL. Cefazolin prophylaxis in obese women undergoing cesarean delivery: a randomized controlled trial. Obstet Gynecol 2015; 125 (05) 1205-1210
- 41 Saville BR, Connor JT, Ayers GD, Alvarez J. The utility of Bayesian predictive probabilities for interim monitoring of clinical trials. Clin Trials 2014; 11 (04) 485-493
- 42 Pedroza C, Tyson JE, Das A, Laptook A, Bell EF, Shankaran S. ; Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network. Advantages of Bayesian monitoring methods in deciding whether and when to stop a clinical trial: an example of a neonatal cooling trial. Trials 2016; 17 (01) 335
- 43 Smid MC, Edwards RK, Biggio JR. , et al. Class III obese women's preferences and concerns for cesarean skin incision: a multicenter survey. Am J Perinatol 2017; 34 (03) 289-294
- 44 Smid MC, Smiley SG, Schulkin J, Stamilio DM, Edwards RK, Stuebe AM. The problem of the pannus: physician preference survey and a review of the literature on cesarean skin incision in morbidly obese women. Am J Perinatol 2016; 33 (05) 463-472