**6.2 Selection of the surgical skin incision**

*Recent Advances in Cesarean Delivery*

ratios in some situations [48].

**6. Surgical considerations**

optimization of post-operative care.

tion of the fetus at time of delivery.

as earlier oxygen desaturation [58].

**6.1 Anesthetic considerations**

**5.2 Informed consent**

surgery.

adapt ergonomics to prevent staff and patient injury, and preparation for known risks in order to safely care for obese patients undergoing planned or unplanned cesarean delivery [44, 48]. It may even be reasonable to increase nurse to patient

Informed consent for cesarean is best initiated well before the operative day, because of the known increase chance of cesarean in obese women, as well as the particular risks described in section 4. Informed consent obtained during labor is known to be particularly brief, and it is unlikely that obstetricians are able to adequately counsel obese patients about their specific risks at time of cesarean delivery [49]. Lack of informed consent can reinforce a claim of medical malpractice [50]. Discussion that includes culturally sensitive and tailored review of the patients' beliefs about her weight may help improve the environment and her delivery experience, and perhaps even impact her health outcomes [51]. It may be reasonable to address and document informed consent during her routine obstetric care visits, and/or at time of admission to the hospital, well in advance of the actual

Challenges facing the obstetric team do not stop at preparation. The performance of a safe cesarean delivery in an obese patient starts with adequate anesthesia, continues with adaptations of surgical technique, and concludes with

General anesthesia, epidural anesthesia, and combined spinal-epidural anesthesia are all options for pain control during cesarean delivery in the obese patient. The choice of anesthetic largely depends on the indication for cesarean and the condi-

Regional anesthesia puncture times for epidural and combined spinal-epidural may be prolonged in the obese patient, and may even contribute to delays in decision to delivery times seen in obese women [31, 52]. There is a higher chance of regional anesthesia failures needing conversion to general anesthesia, and a higher chance of high block during spinal anesthesia necessitating general anesthesia in super obese women (BMI ≥ 50 kg/m2)) [31, 53]. Still, dose reductions for spinal anesthesia have not been proven beneficial in obese patients [54]. The obese patient is at risk for a higher number of punctures at time of spinal placement, simply due to spinal cord distance from skin [41, 55]. Ultrasound guided regional anesthesia placement has been shown to reduce number of punctures in obese women [56]. The risk of regional anesthesia has to be balanced against the risks of general anesthesia in obese patients, which include an inherent difficult airway, transplacental passage of paralytic or sedating medication, and longer incision to delivery times. Pregnancy itself increases the chance of difficult intubation, and obesity appears to multiply this risk – noted to be as high as 33% [57]. The obese patient is also at risk for aspiration (especially if a difficult intubation is encountered), as well

Surgical positioning with a maternal 10–15 degree left lateral tilt is very important in obese women, as their pannus may compress the aorta or vena cava leading

**72**

There is insufficient evidence to conclude a particular skin incision is superior in the performance of a cesarean delivery in obese women. Various choices have been reported including vertical supra-umbilical, vertical or transverse infraumbilical, and the traditional Pfannenstiel with taping of the pannus if necessary, see **Figure 1**. Vertical incisions are associated with a higher chance of vertical/classical uterine incision, but a lower chance of low 1 and 5 minute Apgar score in women with BMI ≥ 40 kg/m<sup>2</sup> [59, 60]. A randomized feasibility trial of 91 women showed no difference in clinical outcomes between Pfannenstiel and vertical skin incisions, and suggested a larger study would have a low chance of finding a difference [61].

Surgeon preferences lean towards a Pfannenstiel skin incision. A study of surgeon preference of incision type on obese patients between Pfannenstiel with or without taping of the Pannus, and vertical in both emergent and non-emergent cesarean delivery, showed the majority preferred Pfannenstiel with taping of the pannus in both cases [62]. Women prioritize safety when it comes to choice of skin incision. A survey of women with BMI ≥ 40 kg/m<sup>2</sup> showed that neonatal and maternal safety ranked higher in priority over cosmetic outcomes in selection of skin incision [63].

Since a superior skin incision has not been clearly shown, it seems reasonable to choose the skin incision based on clinical characteristics of the maternal habitus, and surgeon preference. If a low vertical, or high transverse skin incision is selected in patients with a pannus, care must be taken to ensure the pannus is not transected.

### **6.3 Surgical techniques unique to obese women**

Barrier self-retaining retractors, such as the Doyen or Alexis-O retractor shown in **Figure 2**, may be used to facilitate exposure and reduce the need for additional hands in surgery to provide retraction. This may be particularly helpful in women with a large pannus. The Hook and Doyen retractor apparatus uses hooks and an

#### **Figure 1.**

*Surgical skin incision choices. A – Pfannensteil, B – Supraumbilical, and C – Infraumbilical. The Pannus is elevated using tape bilaterally on the upper abdomen with gentle cephalad traction and anchored to the operating table. Care must be taken when choosing a lower abdominal incision (A or B) to avoid transecting the pannus.*

#### **Figure 2.**

*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 surgeon's way.*

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

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 are also associated with shorter operative times [69].

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 complications in obese patients [70–72].

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].

**75**

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

to prevent surgical site infection. Women with BMI ≥ 30 kg/m2

cohort quality improvement project (unpublished data).

who have either Pfannenstiel or vertical skin incisions [61].

women with class III obesity (BMI ≥ 40 kg/m2

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

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

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

Self-retaining retractors, unfortunately, have also not been found to reduce

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

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

Prophylactic administration of negative pressure wound therapy (Wound

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

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,

drains should be avoided to prevent surgical site infections [70–72].

V.A.C.®, Prevena™) in obese patients with a BMI ≥ 40 kg/m2

application are dropped to women with a BMI ≥ 30 kg/m2

[84]. The use of staples may be

[87].

is associated with

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

may need 3 g of

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

**6.4 Prevention of surgical site infections**

(within 30 days) in obese women [78].

surgical site infection [30, 82].

considered in super-obese women.
