**6.4 Prevention of surgical site infections**

*Recent Advances in Cesarean Delivery*

adjustable chain to attach a retractor placed under the pannus to a railing across the upper end of the operating table. Care must be used as the pannus is displaced on the maternal abdomen and may lead to hypotension and respiratory difficulties,

*Hook and doyen apparatus to retract pannus. The doyen retractor is attached with chains and hooks to a lateral bar on the operating table. The doyen retractor is placed under the pannus to elevate it out of the* 

Longer operative time leads to increased chance of maternal complications including increased blood loss, transfusion, prolonged hospitalization and wound infection [32]. Unfortunately, the very nature of performing a cesarean section in the obese patient necessitates a longer surgery. Surgical techniques associated with shorter operative time may reduce complications. Techniques that favor blunt instead of sharp dissection reduce operative time, such as a modified Misgav-Ladach technique (limited sharp dissection in favor of blunt expansion), blunt expansion of the uterine incision, and finger-assisted stretching technique, or FAST [65–67]. Standardized operative technique also help reduce operative time [68]. Though not studied in obese women specifically, barbed sutures for uterine closure

Evidence suggests that closure of the subcutaneous tissue (if over 2–3 cm in depth) and avoidance of subcutaneous drains decrease the chance of wound com-

There is one known exception to the principle of reducing operative time to improve maternal outcomes. Subcuticular closure with suture reduces chances of wound complications, despite taking more time [73]. The choice of suture (4–0 vicryl or 4–0 monocryl) did not have an effect on wound complications in a randomized controlled trial with a large number (66%) of obese women [74].

especially if the patient is under regional anesthesia [64].

are also associated with shorter operative times [69].

plications in obese patients [70–72].

**74**

**Figure 2.**

*surgeon's way.*

Pre-operative antibiotic prophylaxis within 60 min and prior to skin incision has been associated with a significant reduction in surgical site infection in all women, regardless of their weight. However, the pharmacology of pre-operative antibiotics is altered in obese women. Higher doses of pre-operative antibiotics may be needed to prevent surgical site infection. Women with BMI ≥ 30 kg/m2 may need 3 g of pre-operative cefazolin to achieve similar tissue concentrations of antibiotics as normal and overweight women [75–77]. The addition of a 48-h course of cephalexin and metronidazole in addition to the pre-operative cephalosporin IV prophylaxis has also been shown to reduce the chance of post-operative surgical site infection (within 30 days) in obese women [78].

The addition of azithromycin to standard antibiotic prophylaxis in women of all weight groups undergoing non-elective cesarean delivery has been proven to reduce wound infection [79]. Given the high chance of wound infection in obese patients, it may be reasonable to add azithromycin to standard antibiotic prophylaxis, even in women undergoing elective scheduled cesarean delivery [71]. In our institution, the addition of azithromycin has reduced surgical site infections in a longitudinal cohort quality improvement project (unpublished data).

Different types of skin incisions have not been definitively shown to reduce wound complications. Small studies have shown similar chance of wound complications in obese women with Pfannenstiel and vertical incisions, which is surprising given the moist and microbe rich environment that exists in the skin folds of the pannus [80]. A meta-analysis initially suggested vertical skin incisions may reduce chance of wound infection, but this article was subsequently redacted due to a miscalculation that favored Pfannenstiel for reducing risk of infection [81]. Evidence now suggests no clinical difference in outcomes of women with BMI ≥ 40 kg/m2 who have either Pfannenstiel or vertical skin incisions [61].

Self-retaining retractors, unfortunately, have also not been found to reduce surgical site infection [30, 82].

As mentioned in Section 6.3, subcuticular closure with suture reduces chances of wound complications in obese women [73]. Skin closure with staples is associated with a higher chance of wound complication (infection, separation) in obese women within 6 weeks of delivery [83]. However, this effect did not persist in women with class III obesity (BMI ≥ 40 kg/m2 [84]. The use of staples may be considered in super-obese women.

Many surgeons place prophylactic JP drains in the subcutaneous tissue of obese patients undergoing cesarean delivery, with the thought wound seromas and infection may be prevented. On a large multicenter randomized trial, obese women with subcutaneous drains had similar rates of wound complications as those with subcutaneous fat closure only [85]. However, more recent studies suggest that the subcutaneous tissue should be closed if more than 2–3 cm deep, and subcutaneous drains should be avoided to prevent surgical site infections [70–72].

Prophylactic administration of negative pressure wound therapy (Wound V.A.C.®, Prevena™) in obese patients with a BMI ≥ 40 kg/m2 is associated with a reduction in surgical site infections [86]. Super-obese women may benefit from prophylactic application of negative pressure wound dressings, but a systematic review and meta-analysis suggests this strategy is not beneficial when cut offs for application are dropped to women with a BMI ≥ 30 kg/m2 [87].

Despite implementation of known evidence based measures to prevent surgical site infection (prophylactic antibiotics within 60 min prior to skin incision, chlorhexidine –alcohol for skin antisepsis with 3 min of drying time before incision,


#### **Table 2.**

*Weight based enoxaparin dosing.*

closure of subcutaneous tissue if ≥2 cm depth, and subcuticular skin closure with suture), surgical site infection remains high in obese women [88].

#### **6.5 Prevention of venous thromboembolic events**

Pneumatic compression devices, heparin, and low molecular weight heparin (LMWH) have all been suggested as strategies to reduce VTE in obese women undergoing cesarean delivery. Recommendations from major societies on the strategies for prevention of venous thromboembolism in obese women undergoing cesarean delivery are in conflict [89]. The American College of Obstetricians and Gynecologists (ACOG), the American College of Chest Physicians (ACCP), and the Royal College of Obstetricians and Gynecologists (RCOG) all differ slightly in their published recommendations. ACOG suggests all women undergoing cesarean delivery should use post-partum pneumatic compression devices, but gives no additional specific recommendations regarding obesity [90, 91]. The ACCP suggests obesity is a minor risk factor for VTE, and does not recommend post-partum pharmacoprophylaxis unless two minor risk factors are present [92]. In contrast, the RCOG suggests pharmacoprophylaxis should be administered to women with a BMI > 40 kg/m2 who undergo a cesarean in labor.

Given their higher chance of post-operative VTE, it seems prudent to use at minimum pneumatic compression devices for VTE prophylaxis in obese women undergoing cesarean delivery, and has been found to be cost effective [93]. It seems reasonable to consider VTE pharmacoprophylaxis in women with BMI > 40 kg/m2 , though there is lack of evidence to strongly support this strategy [94]. It is equally important to consider that standard prophylactic doses may not be sufficient to achieve adequate concentrations due to the pharmacokinetics of LMWH in obese persons. Weight-based dosing of enoxaparin (0.5 mg/kg q 12 h) for prevention of thromboembolism is more effective than BMI-stratified dosing (BMI 40–59.9 received 40 mg enoxaparin q 12 h, BMI 60 received 60 mg q 12 h) in achieving adequate anti-Xa concentrations [95–97]. **Table 2** shows a weight-based enoxaparin dosing strategy for obese women.

#### **7. Conclusion**

Cesarean delivery occurs more often in obese women, and increases both maternal and neonatal morbidity. Adequate planning and preparation is required to perform a safe cesarean delivery in obese women, particularly in super-obese patients. Optimal, evidence-based practice includes:

**77**

provided the original work is properly cited.

*Obesity: Unique Challenges at the Time of Cesarean Delivery*

admission, well in advance of operation;

• Adequate physical plant preparation with attention to sufficient equipment,

• Initiation of informed consent process during prenatal care visits or at time of

• Anesthetic consideration and preparation for increased puncture time, num-

• Application of strategies to reduce post-operative wound complications; and

Despite adequate preparation and attention to prophylaxis against known adverse surgical outcomes, the obese patient will have elevated risk above her normal weight counterpart. Prevention of obesity, and adequate weight loss prior to conception is ultimately the best protection against complications at the time of

The authors acknowledge the artistry of Karen Skaret's illustrations included in

ber of punctures, high blocks, and difficult/high risk intubation;

• Consideration of risk for and techniques to reduce risk for venous

• Selection of skin incision and attention to surgical techniques;

*DOI: http://dx.doi.org/10.5772/intechopen.86085*

policy, and staff training;

thromboembolism.

**Acknowledgements**

**Conflict of interest**

**Author details**

Colton, CA, USA

and Guillermo Valenzuela

this Chapter.

cesarean delivery in the obese patient.

The authors have no conflicts of interest to report.

\*Address all correspondence to: kristyroloff@gmail.com

Kristina Roloff\*, Suzanne Cao, Camille Okekpe, Inessa Dombrovsky

Department of Women's Health Arrowhead Regional Medical Center,

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

*Recent Advances in Cesarean Delivery*

closure of subcutaneous tissue if ≥2 cm depth, and subcuticular skin closure with

Pneumatic compression devices, heparin, and low molecular weight heparin (LMWH) have all been suggested as strategies to reduce VTE in obese women undergoing cesarean delivery. Recommendations from major societies on the strategies for prevention of venous thromboembolism in obese women undergoing cesarean delivery are in conflict [89]. The American College of Obstetricians and Gynecologists (ACOG), the American College of Chest Physicians (ACCP), and the Royal College of Obstetricians and Gynecologists (RCOG) all differ slightly in their published recommendations. ACOG suggests all women undergoing cesarean delivery should use post-partum pneumatic compression devices, but gives no additional specific recommendations regarding obesity [90, 91]. The ACCP suggests obesity is a minor risk factor for VTE, and does not recommend post-partum pharmacoprophylaxis unless two minor risk factors are present [92]. In contrast, the RCOG suggests pharmacoprophylaxis should be administered to women with a

Given their higher chance of post-operative VTE, it seems prudent to use at minimum pneumatic compression devices for VTE prophylaxis in obese women undergoing cesarean delivery, and has been found to be cost effective [93]. It seems reasonable to consider VTE pharmacoprophylaxis in women with BMI > 40 kg/m2

though there is lack of evidence to strongly support this strategy [94]. It is equally important to consider that standard prophylactic doses may not be sufficient to achieve adequate concentrations due to the pharmacokinetics of LMWH in obese persons. Weight-based dosing of enoxaparin (0.5 mg/kg q 12 h) for prevention of thromboembolism is more effective than BMI-stratified dosing (BMI 40–59.9 received 40 mg enoxaparin q 12 h, BMI 60 received 60 mg q 12 h) in achieving adequate anti-Xa concentrations [95–97]. **Table 2** shows a weight-based enoxaparin

Cesarean delivery occurs more often in obese women, and increases both maternal and neonatal morbidity. Adequate planning and preparation is required to perform a safe cesarean delivery in obese women, particularly in super-obese

,

suture), surgical site infection remains high in obese women [88].

**Weight (lb) Dose (mg)\*** 200–240 50 241-290 60 291–330 70 331–370 80 371–400 90 >400 100

who undergo a cesarean in labor.

**6.5 Prevention of venous thromboembolic events**

*Administered every 12 h. Adapted from Overcash et al. [95].*

**76**

BMI > 40 kg/m2

*\**

**Table 2.**

*Weight based enoxaparin dosing.*

**7. Conclusion**

dosing strategy for obese women.

patients. Optimal, evidence-based practice includes:


Despite adequate preparation and attention to prophylaxis against known adverse surgical outcomes, the obese patient will have elevated risk above her normal weight counterpart. Prevention of obesity, and adequate weight loss prior to conception is ultimately the best protection against complications at the time of cesarean delivery in the obese patient.
