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Am J Perinatol 2022; 39(05): 539-545
DOI: 10.1055/s-0040-1716889
Original Article

The Association of Cesarean Skin Incision Length and Postoperative Wound Complications

Akila Subramaniam
1   Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Center for Women's Reproductive Health, University of Alabama at Birmingham, Birmingham, Alabama
,
Victoria Jauk
1   Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Center for Women's Reproductive Health, University of Alabama at Birmingham, Birmingham, Alabama
,
George Saade
2   Department of Obstetrics and Gynecology, the University of Texas Medical Branch, Galveston, Texas
,
Kim Boggess
3   Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, Chapel Hill, North Carolina
,
Sheri Longo
4   Ochsner Health System, New Orleans, Louisiana
,
Erin A.S. Clark
5   Department of Obstetrics and Gynecology, The University of Utah, Salt Lake City, Utah
,
Sean Esplin
6   Department of Obstetrics and Gynecology, Intermountain Health-LC, Salt Lake City, Utah
,
Kirsten Cleary
7   Columbia University, New York, New York
,
Ron Wapner
7   Columbia University, New York, New York
,
Kellett Letson
8   Mission Hospital, Asheville, North Carolina
,
Michelle Y. Owens
9   Department of Obstetrics and Gynecology, The University of Mississippi at Jackson, Jackson, Mississippi, the University of Houston, Houston, Texas
,
Sean Blackwell
10   Department of Obstetrics and Gynecology, The University of Houston, Houston, Texas
,
Jeff M. Szychowski
1   Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Center for Women's Reproductive Health, University of Alabama at Birmingham, Birmingham, Alabama
,
William W. Andrews
1   Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Center for Women's Reproductive Health, University of Alabama at Birmingham, Birmingham, Alabama
,
Alan T. Tita
1   Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Center for Women's Reproductive Health, University of Alabama at Birmingham, Birmingham, Alabama
› Author Affiliations Funding This study was supported by the U.S. Department of Health and Human Services, National Institutes of Health, Eunice Kennedy Shriver National Institute of Child Health and Human Development (grant no.: HD64729). The azithromycin used in the parent study was provided by Pfizer through an investigator-initiated grant.
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Abstract

Objective This study was aimed to evaluate the relationship between cesarean skin incision length and wound complications.

Study Design Planned secondary analysis of a multicenter double-blind randomized trial of adjunctive azithromycin versus placebo (in addition to standard cefazolin) in women ≥24 weeks undergoing cesarean delivery during labor or ≥4 hours after membrane rupture. Skin incision length (cm) was measured just prior to skin closure. The primary outcome was a composite of wound complications (wound infection, separation, seroma, hematoma, or dehiscence) up to 6 weeks of postpartum. Individual components of the composite were examined as secondary outcomes. Outcomes were compared between groups defined by the lowest (≤25th), middle (25–75th) and highest (>75th) incision length quartiles. Logistic regression was used to adjust for potential confounding variables.

Results Of the 2,013 women enrolled in the primary trial, 1,916 had recorded incision lengths and were included in this secondary analysis. The overall rate of composite wound complications was 7.8%. Median incision length was 15.0 cm (interquartile range: 14.0–16.5) with the lowest quartile defined as ≤14, middle as >14 to ≤16.5, and highest as >16.5 cm. Mean BMI, parity, use of staples, and duration of surgery differed significantly between the three incision length groups. In unadjusted analysis, the longest incision lengths were associated with an increased risk of the wound composite and wound infections (odds ratio [OR] = 2.27, 95% confidence interval [CI]: 1.43–3.60 and OR = 2.30, 95% CI: 1.27–4.15, respectively) compared with the shortest incision lengths. However, after multivariable adjustments, these associations were nullified. Additional analyses considering incision length as a continuous variable and using 10th/90th percentile cut-offs still did not suggest any associations with outcomes.

Conclusion Increasing skin incision length is not independently associated with an increased risk of postoperative wound complications.

Key Points

  • After multivariable adjustments, skin incision length was not independently associated with an increased risk of postoperative wound complications.

  • A reasonable incision length needed to safely perform the procedure should be used.

Keywords

cesarean - incision length - risk factors - wound complications

Note

This work was presented at the 38th Annual Pregnancy Meeting of the Society for Maternal Fetal Medicine: The Pregnancy Meeting, Dallas, TX, January 29 to February 3, 2018 (Abstract no.: 548).




Publication History

Received: 06 May 2020

Accepted: 20 August 2020

Article published online:
01 October 2020

© 2020. Thieme. All rights reserved.

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  • References

  • 1 Berg CJ, Chang J, Callaghan WM, Whitehead SJ. Pregnancy-related mortality in the United States, 1991-1997. Obstet Gynecol 2003; 101 (02) 289-296
    PubMedGoogle Scholar
  • 2 Creanga AA, Syverson C, Seed K, Callaghan WM. Pregnancy-related mortality in the United States, 2011-2013. Obstet Gynecol 2017; 130 (02) 366-373
    CrossrefPubMedGoogle Scholar
  • 3 Gibbs RS. Clinical risk factors for puerperal infection. Obstet Gynecol 1980; 55 (05) 178S-184S
    CrossrefPubMedGoogle Scholar
  • 4 DeFrances CJ, Cullen KA, Kozak LJ. National hospital discharge survey: 2005 annual summary with detailed diagnosis and procedure data. Vital Health Stat 13 2007; (165) 1-209
    PubMedGoogle Scholar
  • 5 Thigpen BD, Hood WA, Chauhan S. et al. Timing of prophylactic antibiotic administration in the uninfected laboring gravida: a randomized clinical trial. Am J Obstet Gynecol 2005; 192 (06) 1864-1868 , discussion 1868–1871
    CrossrefPubMedGoogle Scholar
  • 6 Costantine MM, Rahman M, Ghulmiyah L. et al. Timing of perioperative antibiotics for cesarean delivery: a metaanalysis. Am J Obstet Gynecol 2008; 199 (03) 301.e1-301.e6
    CrossrefPubMedGoogle Scholar
  • 7 American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 120: Use of prophylactic antibiotics in labor and delivery. Obstet Gynecol 2011; 117 (06) 1472-1483
    CrossrefPubMedGoogle Scholar
  • 8 Tita ATN, Szychowski JM, Boggess K. C/SOAP Trial Consortium. et al. Adjunctive azithromycin prophylaxis for cesarean delivery. N Engl J Med 2016; 375 (13) 1231-1241
    CrossrefPubMedGoogle Scholar
  • 9 Boggess KA, Tita A, Jauk V. Cesarean Section Optimal Antibiotic Prophylaxis Trial Consortium. et al. Risk factors for postcesarean maternal infection in a trial of extended-spectrum antibiotic prophylaxis. Obstet Gynecol 2017; 129 (03) 481-485
    CrossrefPubMedGoogle Scholar
  • 10 Hsu CD, Cohn I, Caban R. Reduction and sustainability of cesarean section surgical site infection: an evidence-based, innovative, and multidisciplinary quality improvement intervention bundle program. Am J Infect Control 2016; 44 (11) 1315-1320
    CrossrefPubMedGoogle Scholar
  • 11 De Vivo A, Mancuso A, Giacobbe A, Priolo AM, De Dominici R, Maggio Savasta L. Wound length and corticosteroid administration as risk factors for surgical-site complications following cesarean section. Acta Obstet Gynecol Scand 2010; 89 (03) 355-359
    CrossrefPubMedGoogle Scholar
  • 12 Ausbeck EB, Jauk VC, Boggess KA. Cesarean Section Optimal Antibiotic Prophylaxis Trial Consortium. et al. Impact of azithromycin-based extended-spectrum antibiotic prophylaxis on noninfectious cesarean wound complications. Am J Perinatol 2019; 36 (09) 886-890
    Article in Thieme ConnectPubMedGoogle Scholar
  • 13 Farret TC, Dallé J, Monteiro VdaS, Riche CV, Antonello VS. Risk factors for surgical site infection following cesarean section in a Brazilian Women's Hospital: a case-control study. Braz J Infect Dis 2015; 19 (02) 113-117
    CrossrefPubMedGoogle Scholar
  • 14 Tran SH, Cheng YW, Kaimal AJ, Caughey AB. Length of rupture of membranes in the setting of premature rupture of membranes at term and infectious maternal morbidity. Am J Obstet Gynecol 2008; 198 (06) 700.e1-700.e5
    CrossrefPubMedGoogle Scholar
  • 15 Ghuman M, Rohlandt D, Joshy G, Lawrenson R. Post-caesarean section surgical site infection: rate and risk factors. N Z Med J 2011; 124 (1339): 32-36
    PubMedGoogle Scholar
  • 16 Olsen MA, Butler AM, Willers DM, Devkota P, Gross GA, Fraser VJ. Risk factors for surgical site infection after low transverse cesarean section. Infect Control Hosp Epidemiol 2008; 29 (06) 477-484 , discussion 485–486
    CrossrefPubMedGoogle Scholar
  • 17 Wloch C, Wilson J, Lamagni T, Harrington P, Charlett A, Sheridan E. Risk factors for surgical site infection following caesarean section in England: results from a multicentre cohort study. BJOG 2012; 119 (11) 1324-1333
    CrossrefPubMedGoogle Scholar