Sunday, January 29, 2012

More Evidence That Vertical Incisions Have Increased Complications

We have blogged about this before, but here's yet another study that vertical (up-down) cesarean incisions in "obese" women have more complications than low transverse (side-to-side) incisions.

As we've  noted before, sometimes there can be legitimate justification for using a vertical incision. However, most of the time, its use in fat women springs from outdated and non evidence-based teachings that an incision under the belly (pannus) predisposes the wound to infection, and that a vertical incision will supposedly lower the risk for infection and improve outcomes. 

Yet when researchers finally got around to actually studying the question, they found that vertical incisions either did not improve outcome OR significantly worsened it, as in this study, where incision type was associated both with infectious complications and with wound separation.

Notice that in this study, ~46%% of "morbidly obese" women with vertical incisions experienced a wound complication of some sort.  Nearly half!   

In comparison, only ~12% of morbidly obese women with low transverse incisions experienced a wound complication.

Yet still, despite more complications with vertical incisions, about 7% of obese women in this study (11% in others) are being subjected to vertical incisions instead of low transverse incisions during cesareans.  That's around 1 out of every 10 to 14 obese women having a cesarean. That's far too high a rate, considering the poorer medical and cosmetic outcomes with vertical incisions.

More and more data is accumulating to show that the most optimal incision is usually the low transverse incision, even in very fat women.  When will doctors heed their own research?

J Matern Fetal Neonatal Med. 2012 Jan 10. Risk factors for wound complications in morbidly obese women undergoing primary cesarean delivery. Thornburg LL, et al.   PMID: 22233403

Source: Department of Obstetrics & Gynecology, Maternal Fetal Medicine, University of Rochester Medical Center, Rochester, NY, USA.
Objective: To determine factors influencing separation and infectious-type wound complications (WC) in morbidly obese women undergoing primary cesarean delivery (CD).  
Methods: Retrospective cohort study evaluating infectious and separation WC in morbidly obese (Body mass index (BMI) greater than 35) women undergoing primary CD between 1/1994 and 12/2008. Chi-square, Fisher's exact, and Student's t-test used to assess associated factors; backwards logistic regression to determine unadjusted and adjusted odds ratios.  
Results: Of 623 women, low transverse skin incisions were performed in 588 (94.4%), vertical in 35 (7%). Overall WC rate was 13.5%, which varied by incision type (vertical 45.7% vs. 11.6% transverse; p less than 0.01), but not BMI class. Incision type and unscheduled CD were associated with infection risk, while incision type, BMI, race, and drain use were associated with wound separation.  
Conclusion: In morbidly obese women both infectious and separation-type WC are more common in vertical than low transverse incisions; therefore transverse should be preferred.


Momma Of 2 TandK said...

I was cut this way and I was not even obese at the time :( I was then re-cut the same way for my second birth of course. Both c-secs unnecessary but I won't even get into that. My Dr. claimed to have cut me that way because I was expecting a big baby *sigh*

Anonymous said...

I was 'morbidly obese' with my second, who was c-section due to the heartrate not recovering and all sorts of things that slowed down labor until it was dangerous. The cut was a low horizontal cut, I had discussed with my doctor how I wanted more children and he had done that even though I had been laboring and he suspected a big baby (wasn't big.) I didn't realize how lucky I was that he cut me like that rather than vertical until far later. I was up and about immediately, within a week the wound was nearly healed, within 2 weeks the stitches were taken out, and within 3 you could hardly tell where the cut was unless you knew. All of this with a huge apron laying over it (I'm not small.)

Any doctor who says that they can't because of a woman's size needs replacing. My doctor may not be perfect in a lot of ways, but even he handled the low horizontal with no problems.

Anonymous said...

Thank you so much for posting this research. I am being faced with a c-section and the doctor is pressing to do the 'classical' vertical incision, which had seemed idiotic to me at the time and even more irresponsible now given the research you have listed.

The research you presented will help me defend my position and either make me find a new OB at 37w or at least get a healthier c-section.