**2.3 Pathological obesity**

Obesity is a risk factor for a cesarean section. Considering the obesity epidemic, it is not surprising that doctors are increasingly called upon to perform cesarean sections for obese women (BMI ≥ 30) [10, 11]. The results of a secondary analysis of the FASTER study indicate that a cesarean section is more common in obese and morbidly obese individuals than in normal weight subjects (20.7 vs. 33.8 vs. 47.4%, respectively) [12]. A cesarean section in morbidly obese subjects involves an increased risk of complications such as increased technical difficulty of the surgical procedure, poor wound healing, and increased potential risk of venous thromboembolism [13]. The need for a cesarean section is due to both maternal and fetal factors: the greater difficulty in monitoring fetal heart rate and a more likely dystocia of labor lead to the execution of an earlier and more complex cesarean section. During surgery, the surgeon must assess the skin incision, balancing the most efficient extraction of the fetus and optimal wound healing (**Figure 1**).

Rather than a vertical midline incision, the Pfannenstiel or Joel-Cohen incision is associated with less abdominal tension and less complications in situations of increased intra-abdominal pressure, such as a chronic cough. In a morbidly obese woman with a large abdominal panniculus, wound healing may be impaired due to the continued presence of moisture in the area. If the adipose panniculus is not mobile or the anatomy of the abdomen is altered, it should be better to make a supra-umbilical incision, over the anterior and fundic portion of the uterus, in order to facilitate fetal extraction. This approach has to be preferred in women who opt for tubal ligation and who do not plan further pregnancies as high uterine incisions are associated with a greater risk of subsequent uterus ruptures. Regardless of the type of incision, the current recommendations provide for the execution of a subcutaneous suture when the subcutaneous fat has a thickness greater than 2 cm, to prevent the formation of a seroma and the dehiscence of the wound. If the incision is subjected to a large amount of moisture due to the presence of skin folds, it is wise to leave a dressing covering the healing skin until the risk of wound. Dehiscence has reduced, to avoid the formation of a seroma [14]. In contrast, there is no evidence that subcutaneous drainage is effective in preventing postoperative morbidity.

Additional considerations must be taken into account when performing a cesarean section on morbidly obese individuals. A pragmatically important indication is to

#### **Figure 1.** *Laparotomic abdominal incisions. a. (left) Representation of variants. b. (right) Xifopubic incision.*

make sure that the operating table can support the patient's weight, especially when tilted or placed in the Trendelenburg position. While lying in a supine position, a patient may experience shortness of breath. This sensation may not be relieved by releasing the pressure of the uterus on the inferior vena cava with the insertion of a wedge to maintain the left lateral tilt position. In these situations, raising the head of the bed by 15°–20° is sufficient to relieve the feeling of shortness of breath. Obesity affects anesthesia choices; it may not be possible to apply epidural analgesia due to inadequate length of the spinal needle, inability to reach anatomical landmarks, and irregular distribution of drugs in the blood. If regional anesthesia is ineffective or impossible, the patient must undergo general anesthesia, which involves its own risks, including aspiration of gastric material and transplacental transfer of drugs. Since there is an increased risk of venous thromboembolism, both mechanical and pharmacological prophylaxis must be performed in morbidly obese women. Finally, due attention should be paid to the administration of correct antibiotic dosage, taking into account the potentially increased volume of distribution of these drugs.
