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10 practical, evidence-based recommendations for improving maternal outcomes of cesarean delivery

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Recent studies shed light on anesthesia, postoperative adhesions, infectious morbidity, and the risk of bladder and ureteral injuries in cesarean delivery


Cesarean delivery is not risk-free, despite its high prevalence (30% overall, but almost 100% in women who have more than two prior cesareans). It increases the risks of adhesions, severe blood loss, and injury to the bowel, bladder and ureters, particularly among women undergoing the procedure for the second or third time.

Morbidly obese women (i.e., those who have a body mass index [BMI] of 40 or above) are in a particular bind: They have an elevated risk of cesarean delivery, and when they undergo the procedure, they have a significantly heightened risk of cardiopulmonary complications, anesthetic complications, wound complications, thromboembolism, and prolonged skin incision-to-delivery time.

A number of studies have described the technical aspects of cesarean delivery, but debate continues about a number of issues:

  • the risks and benefits of types of skin incision
  • whether the rectus muscle should be separated bluntly or sharply
  • whether or not to close the peritoneum
  • the best method of closing the skin (i.e., subcuticular sutures or staples).

In this review, I offer 10 practical, evidence-based recommendations that help clarify these issues, including several that focus on the morbidl obese population.

1. Anticipate anesthetic complications

In morbidly obese pregnant women, plan for potential complications

Vricella LK, Lois JM, Mercer BM, Bolden N. Anesthesia complications during scheduled cesarean delivery for morbidly obese women. Am J Obstet Gynecol. 2010;203(3):276.e1–5.

Knight M, Kurinczuk JJ, Spark P, Brocklehurst P; UK Obstetric Surveillance System. Extreme obesity in pregnancy in the United Kingdom. Obstet Gynecol. 2010;115(5):989–997.

In a national cohort study of 665 women who had a BMI of 50 or above, 11% experienced problems with epidural anesthesia, including failure; 6% required general anesthesia; and 3% required admission to intensive care. A similar, but retrospective, study of 142 morbidly obese women found an anesthesia complication rate of 8.5%.

These studies suggest that planning and antenatal consultation with anesthesiologists are important to help avert anesthetic complications during cesarean delivery. Requirements include detailed evaluation at admission, early placement of an epidural catheter, preparation for general anesthesia in case of failure of regional anesthesia, and ensuring the availability of an anesthesiologist who has expertise in this population.

2. Reduce the interval from decision to delivery

Plan, implement, and rehearse a protocol to move from decision to incision and delivery in 30 minutes in morbidly obese women

Lucas DN. The 30-minute decision to delivery time is unrealistic in morbidly obese women. Int J Obstet Anesth. 2010;19(4):431–435. Comment by: Dresner M. Int J Obstet Anesth. 2010;19(4):435–437.

Although several national bodies recommend a decision-to-incision or delivery interval of 30 minutes or less, this approach is not backed by definitive data. Moreover, the 30-minute goal poses major challenges to the nursing, anesthesia, and surgical teams that provide care to morbidly obese women who require emergent cesarean delivery. This is especially true in cases that involve catastrophic events, such as abruptio placentae, cord prolapse, uterine rupture, or vasa previa—where minutes matter.

Nevertheless, efforts to reduce this interval are vital. Consider four phases:

  • how long it takes to transfer the patient to the operating room
  • the time it takes to position and prepare the patient for surgery
  • the time required to administer anesthesia
  • how long it takes to move from skin incision to delivery of the fetus.

Because all four phases will be prolonged in morbidly obese patients, it is prudent for obstetric units to develop protocols to identify and flag women who are at risk, and to have policies and procedures in place to reduce these times. This will necessitate drills for rehearsal and testing of response times and skills of the various providers. In addition, whenever emergent cesarean is performed, the actual response time and effectiveness of interventions should be evaluated.

3. Consider a transverse skin incision

In morbidly obese women who undergo emergent cesarean delivery, a transverse skin incision may provide benefit

Wylie BJ, Gilbert S, Landon MB, et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Maternal-Fetal Medicine Units Network (MFMU). Comparison of transverse and vertical skin incision for emergency cesarean delivery. Obstet Gynecol. 2010;115(6):1134–1140.

Bell J, Bell S, Vahratian A, Awonuga AO. Abdominal surgical incisions and perioperative morbidity among morbidly obese women undergoing cesarean delivery. Eur J Obstet Gynecol Reprod Biol. 2011;154(1):16–19.

No randomized trials have compared the benefits and risks of vertical and transverse skin incisions during cesarean delivery. In general, a vertical incision is believed to shorten the time to delivery, but is associated with a greater need for transfusion, greater postoperative pain, and higher rates of wound dehiscence and infection, compared with a transverse incision.


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