Original Article 301

Type of Skin Incision and Wound Complications

in the Obese Parturient
Mamie McLean, M.D. 1 Rachel Hines, B.S. 1 Margaret Polinkovsky, D.R.P.H. 2 Alison Stuebe, M.D. 1
John Thorp, M.D. 1 Robert Strauss, M.D. 1

1 Department of Obstetrics and Gynecology, University of North Address for correspondence and reprint requests Robert Strauss,
Carolina at Chapel Hill, Chapel Hill, North Carolina M.D., University of North Carolina, Campus Box 7516, Chapel Hill, NC
2 UNC Gillings School of Global Public Health, Chapel Hill, North 27599 (e-mail: [email protected]).
Carolina

Am J Perinatol 2012;29:301–306.

Abstract We examined the relationship between type of skin incision at time of cesarean delivery
and postoperative wound complications in the obese parturient. Women with a body

Downloaded by: Florida International University. Copyrighted material.

mass index (BMI) of greater than 29 who had undergone cesarean delivery at The
University of North Carolina were identified from the Pregnancy, Infection and Nutrition
study. Inpatient and outpatient medical records were reviewed for maternal demo-
graphics as well as intrapartum and intraoperative characteristics. The exposure of
interest was type of incision, classified as vertical or transverse. The primary outcome
was wound complication, defined as partial or complete wound separation. Logistic
regression analysis was used to create a final model of risk factors for wound
complications while controlling for potentially confounding variables. From 1998 to
2005, 238 women with a BMI greater than 29 who underwent cesarean delivery were
identified. Of these 238 women, a vertical skin incision was performed in 25 (11%) and a
transverse skin incision in 213 (89%). The overall incidence of wound complications in
this group was 13%. BMI was associated with wound complications (p < 0.01). After
controlling for confounding factors, no difference in wound complication based on type
of skin incision was apparent. The type of skin incision does not appear to be associated
Keywords
with wound complications in the obese parturient; however, larger studies would be
► obesity
needed to confirm this finding. Increased BMI is associated with a higher rate of wound
► cesarean
complications.
► wound complications

Providers in women’s health care are finding that the obesity among nulliparous women found a 30% cesarean rate among
epidemic is reaching their patients at alarmingly high rates. obese women, compared with 16% of normal controls. They
A large cohort study found that 29% of women aged 20 to 39 also found a direct relationship between body mass index
were obese.1 In a population-based study of obesity trends in (BMI) and cesarean delivery.6
the United States from 1994 to 2003, prepregnancy obesity Obesity also increases the risk of wound complications
increased nearly 70%.2 after cesarean delivery. In a review of over 142,404 pregnan-
Obesity increases the risk of gestational diabetes, macro- cies, investigators found an increased risk of wound infection
somia, cephalopelvic disproportion, failed induction, failed (odds ratio ¼ 1.6) among obese versus nonobese patients.7
vaginal birth after cesarean, and thus increases the risk of Wound complications are quite disruptive to new mothers,
cesarean delivery.3–5 A large retrospective cohort study often requiring trips back to the operating room,

received Copyright © 2012 by Thieme Medical DOI http://dx.doi.org/

July 14, 2011 Publishers, Inc., 333 Seventh Avenue, 10.1055/s-0031-1295637.
accepted after revision New York, NY 10001, USA. ISSN 0735-1631.
July 16, 2011 Tel: +1(212) 584-4662.
published online
November 21, 2011
302 Skin Incision and Wound Complications in the Obese Parturient McLean et al.

cumbersome wound vacuum devices, and multiple doctor number of incision type, with 80% power and a two-tailed α of
visits and dressing changes. Such complications also marked- 0.05.12
ly increase medical costs.8 SAS 9.2 (SAS Institute Inc, Cary, NC) was used for all
Previous studies of risk factors for wound complications statistical analysis. Univariable and multivariable statistics
have identified several potential variables, many of which are were calculated. Nominal variables were assessed by χ2 or
outside a physician’s control, such as need for intrapartum Fisher exact test as appropriate. Continuous variables were
cesarean section, maternal BMI, and endomyometritis. One assessed by Student t test or Wilcoxon rank test as appropri-
potentially modifiable risk factor is type of skin incision. ate. Stepwise logistic regression analysis was used to create a
Surgeons who choose a vertical skin incision may experi- final model of risk factors for wound separation. Variables
ence less blood loss and shorter operative times and avoid the that were found to be significant (p < 0.2) were included in
warm moist skin under a maternal pannus. Surgeons who our final analysis. We did not include exposures that occurred
choose a transverse skin incision may have less subcutaneous after the exposure of interest (type of skin incision) such as
tissue dissection, more secure closure, and better tissue estimated blood loss, uterine incision, use of drains, or
oxygenation postoperatively as these patients may have subcutaneous closure. It is standard practice at our institution
less postoperative pain and presumably earlier ambula- to use 2 g of intravenous cefazolin prior to skin incision for all
tion.9,10 No prospective trials have examined type of skin cesarean deliveries. All vertical skin incisions were closed
incision in relation to wound complications. Two retrospec- with staples, and thus, we were not able to control for type of
tive studies have found conflicting results.11,12 Given these skin closure in our model of risk. We also included the two
inconclusive data, we sought to determine if the type of skin exposures of indication for cesarean and tobacco in our final

Downloaded by: Florida International University. Copyrighted material.

incision at cesarean delivery alters an obese patient’s risk of a model, despite not reaching significance, due to small sample
wound complication. size and potential for interaction. Statistical significance was
set at a p value of 0.05. Odds ratios with 95% confidence
intervals were determined where appropriate. The Institu-
Materials and Methods
tional Review Board for the University of North Carolina at
We performed a secondary analysis of the Pregnancy, Infec- Chapel Hill approved the study.
tion and Nutrition (PIN) study, which was a large observa-
tional cohort study that examined the effect of infection,
Results
stress, physical activity, and nutrition on preterm births
(http://www.cpc.unc.edu/projects/pin). The study enrolled From 1995 to 2005, the PIN study recruited 5169 women. Of
women with singleton pregnancies who received prenatal these, 828 (16%) had a BMI 30, and 242 (29%) of this obese
care from the University of North Carolina and Wake Medical subgroup underwent cesarean delivery. Four women (1.6%)
Centers from 1998 to 2005. Participants were enrolled in were excluded secondary to inadequate medical records,
midpregnancy and agreed to participate in several study leaving 238 women for the final analysis. The characteristics
interviews, questionnaires, and assessments. of this cohort are presented in ►Table 1. More patients
We included all patients with a BMI 30 who delivered at underwent a transverse skin incision compared with a verti-
University of North Carolina Hospitals by cesarean delivery. We cal skin incision (89% versus 11%, respectively).
excluded patients with incomplete medical records. A record When compared with women with a transverse incision,
was deemed incomplete if any demographic information, BMI, women with a vertical skin incision had a higher BMI and
operative note, or anesthetic record was unavailable. were more likely to be diagnosed with pregestational diabe-
Using hospital medical records, demographic and perina- tes, chronic hypertension, or preeclampsia.
tal information was collected, including maternal age, ethnic- We found 27 cases (11%) of wound separation among our
ity, insurance status, medical complications, tobacco use, 238 study subjects. Twenty-three (85%) were diagnosed in the
maternal BMI at first prenatal visit, prior abdominal surgery, outpatient setting and 4 (15%) occurred prior to discharge.
preeclampsia, gestational age at delivery, indication for ce- Patients who did not have a postpartum visit were included
sarean delivery, type of anesthesia, wound separation, and in the analysis. In bivariate analysis, only higher BMI
type of skin incision. Wound complications were identified by was associated with increased risk of wound separation
searching inpatient hospital records for each patient, as well (►Table 2). In logistic regression models, we found a direct
as all emergency department and outpatient visits through 6 association between BMI and risk of wound separation, with a
weeks’ postpartum. International Classification of Diseases, statistically significant quadratic term, indicating that the risk
Ninth Revision codes (674.34, 674.1, 674.32, and 674.12) were of wound separation does not increase linearly with higher
also used to identify any patients with wound complications. BMI. Our number of patients with a BMI >40 was too small
The exposure of interest was type of skin incision (trans- to perform subgroup analysis. Patients with a vertical skin
verse versus vertical); the primary outcome was wound incision also had a higher incidence of wound separation (20%
separation defined as partial or complete wound separation. versus 10%), although this difference did not reach statistical
Sample size estimation determined that 228 patients were significance (p ¼ 0.15).
needed to detect a 50% reduction in wound separation, The results of our final regression analysis are shown
assuming a 34% rate of wound separation among obese in ►Table 3. BMI was the only variable associated with type
patients with a vertical skin incision and assuming an equal of skin incision and wound separation. We found that the

American Journal of Perinatology Vol. 29 No. 4/2012

 Skin Incision and Wound Complications in the Obese Parturient McLean et al. 303

Table 1 Patient Characteristics Stratified by Type of Skin Incision

Characteristics Vertical Skin Incision (n ¼ 25) Transverse Skin Incision (n ¼ 213) p Value
Age 29.4  5.2 29.9  6.0 0.72
Ethnicity 0.20
White 10 (40) 124 (58)
Black 13 (52) 77 (36)
Other 2 (8) 13 (6)
Insurance 0.63
Medicaid 8 (32) 70 (33)
Private 13 (52) 122 (57)
Uninsured 4 (16) 21 (10)
Diabetes 0.004
None 12 (48) 164 (77)
Gestational 5 (20) 25 (12)
Pregestational 8 (32) 23 (11)
Tobacco use 8 (32) 44 (21) 0.19
Maternal BMI 43 (36–51) 36 (32–40) <0.01
Prior abdominal surgery 0.22

Downloaded by: Florida International University. Copyrighted material.

None/laparoscope 9 (36) 107 (50)
Cesarean/laparotomy 15 (56) 104 (48)
Chronic hypertension 11 (44) 55 (26) 0.06
Preeclampsia 7 (28) 28 (13) 0.05
Gestational age at delivery (wk) 39 (37–39) 39 (37–39) 0.61
Indication for cesarean 0.83
Planned 14 (56) 124 (58)
Unplanned 11 (44) 89 (42)
Anesthesia 0.01
Spinal 10 (40) 112 (53)
Epidural 11 (44) 94 (44)
General 4 (16) 7 (3)
Wound separation 5 (20) 22 (10) 0.15

Data are presented as mean  standard deviation, median (interquartile range), or n (%). BMI, body mass index.

relationship between BMI and wound separation was not The other study by Wall et al9 included a larger cohort of
linear, and this was accounted for in our final model. patients (n ¼ 239) but the researchers followed the patients
for wound complications only until postoperative day 4 or 5,
when they were discharged from the hospital. Wall et al9
Discussion
found that vertical skin incisions were associated with higher
In a study of 238 obese women undergoing cesarean delivery, rates of wound complications (odds ratio ¼ 12.4; p < 0.001).
we found a higher rate of wound separation among women The strengths of our study include that both inpatient and
with vertical skin incision, but this difference was not sta- outpatient wound complications were identified. Previous
tistically significant. This may be due to increased tension on studies failed to identify outpatient wound separations,
the wound, increased subcutaneous tissue, decreased post- which accounted for more than half of our complications.
operative ambulation, and less tissue perfusion. In addition, Most of the wound complications in our study occurred 1 to
the risk of wound separation increased as patient BMI 2 weeks after discharge. Finally, we were able to include a
increased. broader range of potentially confounding factors than previ-
Our findings extend earlier work on the association be- ous studies.
tween type of skin incision and wound separation. Houston Our findings must be interpreted in the context of the
and Raynor8 compared wound complications in morbidly study design. This is a secondary analysis of an observational
obese patients in a retrospective case control study. Patients cohort study, and therefore, unmeasured factors associated
were eligible for enrollment if their body weight was greater with risk of wound separation may have affected the sur-
than 150% of ideal body weight. They had only 15 patients in geon’s decision to use a vertical or transverse skin incision.
their supraumbilical group and only 54 in the Pfannenstiel Moreover, our ascertainment of wound separation may be
group .They found no difference in wound complications incomplete, because we were limited to searching outpatient
between the two types of incisions. records at our own institution, and patients who did not

American Journal of Perinatology Vol. 29 No. 4/2012

304 Skin Incision and Wound Complications in the Obese Parturient McLean et al.

Table 2 Patient Characteristics Stratified by Wound Complication

Characteristic Wound Separation (n ¼ 27) No Wound Separation (n ¼ 211) p Value

Age 30.7  7.3 29.7  5.9 0.41
Ethnicity 0.49
White 19 (70) 115 (55)
Black 7 (26) 83 (39)
Other 1 (4) 13 (6)
Insurance 0.35
Medicaid 8 (30) 70(33)
Private 14 (52) 121 (57)
Uninsured 5 (19) 20 (9)
Diabetes 0.95
None 20 (74) 156 (74)
Gestational 3 (11) 27 (13)
Pregestational 4 (15) 28 (13)
Tobacco 20 (74) 7 (26) 0.59
BMI 40 (36–44) 36 (32–44) <0.01
Prior abdominal surgery 0.83

Downloaded by: Florida International University. Copyrighted material.

None/laparoscopy 14 (53) 105 (50)
Cesarean/laparotomy 13 (48) 106 (50)
Chronic hypertension 9 (33) 57 (27) 0.49
Preeclampsia 3 (11) 32 (15) 0.58
Indication for cesarean 0.49
Planned 14 (52) 124 (59)
Unplanned 13 (48) 87 (41)
Anesthesia 0.47
Spinal 14 (52) 108 (51)
Epidural 13 (48) 92 (44)
General 0 11 (5)
Skin incision 0.15
Vertical 22 (81) 191 (91)
Pfannenstiel 5 (19) 20 (9)

Data are presented as mean  standard deviation, median (interquartile range), or n (%). BMI, body mass index.

return for a postpartum visit or wound complication could rate in our study, 438 patients would be needed in a prospec-
have been missed. Postoperative techniques such as timing of tive trial to show any difference in wound separation based on
staple removal and techniques of keeping the incision dry type of skin incision.
underneath a maternal pannus were not standardized in our To fully answer the question of optimal skin incision in the
patient population. In addition, our study is based on a cohort obese parturient, a multicenter randomized control trial is
of women with singleton pregnancies who received prenatal needed. Including patients with extremely high BMIs would
care prior to 20 weeks and agreed to participate in a longitu- be important to adequately examine wound complications in
dinal research study. Our results, therefore, may not be this subgroup, particularly because our study suggests that
generalizable to populations that present later to prenatal the incidence levels off after a certain BMI. A prospective
care. Last, our study was underpowered due to the low study could address postoperative incision hygiene or tech-
incidence of vertical skin incisions and wound separations. niques that could keep the incision dry beneath a mater-
In fact, we had only 10% power to detect a difference in wound nal pannus. Last, general surgery literature has suggested
separation between the types of skin incisions, leaving our that obese patients have lower tissue penetration of cepha-
study vulnerable to a type 2 error. Based on the complication losporins, perhaps leading to increased risk of wound

Table 3 Final Regression Model of Type of Skin Incision and Odds of Wound Separation

Unadjusted OR Adjusted ORa p Value

Vertical skin incision 2.2 2.8 0.11 (adjusted)
0.16 (unadjusted)
a
Adjusted for body mass index, labor, diabetes, and ethnicity (Caucasian versus other). OR, odds ratio.

American Journal of Perinatology Vol. 29 No. 4/2012

 Skin Incision and Wound Complications in the Obese Parturient McLean et al. 305

complications.13 Further investigation of dosing of antibiotics 4 Hibbard JU, Gilbert S, Landon MB, et al; National Institute of Child
for wound prophylaxis in the obese patient is needed in the Health and Human Development Maternal-Fetal Medicine Units
obstetrics population. Network. Trial of labor or repeat cesarean delivery in women with
morbid obesity and previous cesarean delivery. Obstet Gynecol
In conclusion, we found that vertical skin incisions are
2006;108;125–133
associated with increased odds of postoperative wound sep- 5 Cedergren MI. Maternal morbid obesity and the risk of adverse
aration, although this difference did not reach statistical pregnancy outcome. Obstet Gynecol 2004;103;219–224
significance. Although many variables factor into a surgeon’s 6 Bhattacharya S, Campbell DM, Liston WA, Bhattacharya S. Effect
decision on what type of skin incision to perform, the results of body mass index on pregnancy outcomes in nulliparous
women delivering singleton babies. BMC Public Health 2007
of our study do not support the use of vertical skin incisions to
7;168
reduce wound complications among obese women at the
7 Robinson HE, O’Connell CM, Joseph KS, McLeod NL. Maternal
time of cesarean delivery. outcomes in pregnancies complicated by obesity. Obstet Gynecol
2005;106;1357–1364
8 Olsen MA, Butler AM, Willers DM, Gross GA, Hamilton BH, Fraser
Acknowledgments VJ. Attributable costs of surgical site infection and endometritis
after low transverse cesarean delivery. Infect Control Hosp Epi-
Supported by National Institute of Child Health and
demiol 2010;31;276–282
Human Development, National Institutes of Health grant 9 Grantcharov TP, Rosenberg J. Vertical compared with transverse
numbers HD28684A and HD37584. incisions in abdominal surgery. Eur J Surg 2001;167;260–267
10 Brown SR, Goodfellow PB. Transverse verses midline incisions for
abdominal surgery. Cochrane Database Syst Rev 2005;(4):

Downloaded by: Florida International University. Copyrighted material.

CD005199
References 11 Houston MC, Raynor BD. Postoperative morbidity in the morbidly
1 Hedley AA, Ogden CL, Johnson CL, Carroll MD, Curtin LR, Flegal KM. obese parturient woman: supraumbilical and low transverse
Prevalence of overweight and obesity among US children, adoles- abdominal approaches. Am J Obstet Gynecol 2000;182;1033–
cents, and adults, 1999–2002. JAMA 2004;291;2847–2850 1035
2 Kim SY, Dietz PM, England L, Morrow B, Callaghan WM. Trends in 12 Wall PD, Deucy EE, Glantz JC, Pressman EK. Vertical skin incisions
pre-pregnancy obesity in nine states, 1993–2003. Obesity (Silver and wound complications in the obese parturient. Obstet Gynecol
Spring) 2007;15;986–993 2003;102(5 Pt 1):952–956
3 Baeten JM, Bukusi EA, Lambe M. Pregnancy complications and 13 Edmiston CE, Krepel C, Kelly H, et al. Perioperative antibiotic
outcomes among overweight and obese nulliparous women. Am J prophylaxis in the gastric bypass patient: do we achieve thera-
Public Health 2001;91;436–440 peutic levels? Surgery 2004;136;738–747

American Journal of Perinatology Vol. 29 No. 4/2012

Downloaded by: Florida International University. Copyrighted material.