Am J Perinatol 2024; 41(06): 778-782
DOI: 10.1055/a-1788-6381
Original Article

Skin Incision Selection in Superobese Women Undergoing Cesarean Birth

Jennifer L. Grasch
1   Department of Obstetrics and Gynecology, Indiana University Medical Center, Indianapolis, Indiana
Jennifer L. Thompson
2   Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, Tennessee
Lamia A. Alamri
2   Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, Tennessee
Sarah S. Osmundson
2   Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, Tennessee
› Author Affiliations
Funding U.S. Department of Health and Human Services, National Institutes of Health, National Institute on Drug Abuse, K23DA047476


Objective The aim of this study was to examine whether vertical versus transverse skin incision is associated with increased wound complications in superobese women undergoing cesarean.

Study Design This is a secondary analysis of a retrospective cohort study that included women with a body mass index (BMI) ≥ 50 kg/m2 and a cesarean birth with documented skin incision type from 1/1/2008 to 12/31/2015 at a single academic medical center. The primary outcome was a composite of wound complications: infection requiring antibiotics including superficial cellulitis, deep and organ space infections requiring packing, vacuum placement or exploration and debridement in the operating room. Secondary outcomes included estimated blood loss (EBL), time from skin incision to delivery, need for classical or T-hysterotomy, prolonged hospital admission (>4 days), and a composite of adverse neonatal outcomes. The primary exposure was skin incision type, transverse or vertical. Modified Poisson regression variance was used to adjust for differences in baseline characteristics.

Results During the study period, 298 women underwent a cesarean with a known skin incision type. Vertical skin incision occurred in 25.8%. Women with a vertical skin incision were younger, had a higher BMI at delivery, had less weight gain in pregnancy, and were less likely to have labored prior to cesarean. Wound complications were not significantly more common in women with a vertical skin incision after adjusting for covariates (vertical 48.1 vs. transverse 29.4%, adjusted relative risk (aRR): 1.31, 95% confidence interval [CI]: 0.92–1.86). Compared with a transverse skin incision, vertical skin incision was associated with an increased risk for classical hysterotomy (67 vs. 17%, aRR: 2.96, 95% CI: 2.12–4.14), higher EBL, prolonged hospital stay, and composite neonatal morbidity. There were no statistically significant differences in the time from skin incision to delivery.

Conclusion In superobese women, vertical skin incision was not associated with increased wound complications, but was associated with increased risk for classical hysterotomy.

Key Points

  • Vertical skin incision was not associated with a higher risk for composite wound morbidity after adjusting for covariates.

  • Vertical skin incision was significantly associated with classical hysterotomy without associated decrease in incision to delivery time or neonatal morbidity.

  • When selecting a skin incision approach in superobese women, clinicians should consider whether potential benefits outweigh known risks.

Publication History

Received: 17 February 2021

Accepted: 18 February 2022

Accepted Manuscript online:
04 March 2022

Article published online:
12 May 2022

© 2022. Thieme. All rights reserved.

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