Exercise During Pregnancy May Cut Labor Length in Women of Size

Image from Stocky Bodies Image Bank

Here is the abstract of a recent study that found that exercise during pregnancy might be useful in reducing how long a high-BMI woman spends in labor.

In the study, women of size who were active during pregnancy had shorter labors (13.4 hours vs. 19.2 hours) than those who were more sedentary.

The effect seemed particularly strong for women who had given birth before (multips). "Obese" multips who were active in pregnancy had labors of about 6.2 hours, vs. 16.7 hours for obese multips who were not active in pregnancy.

The difference in cesarean rates between those who were active in pregnancy and those who were not did not rise to statistical significance in this study, but as we wrote about recently, other research has suggested that exercise in pregnancy might reduce the risk for cesareans as well.

One caution is that this study was small, so that limits the conclusions from it. Perhaps there were simply not enough participants to show a significant difference in cesareans. On the other hand, its relatively small size might also have magnified the effect on labor length. So there is that caveat.

And of course, this finding is only a correlation. There are plenty of people who exercise religiously and end up with long labors and/or cesareans, and some people who don't exercise at all and have easy short labors and births. Exercising is no guarantee of anything, but it does seem likely to reduce the odds of problems. For example, some research suggests that regular exercise during pregnancy might reduce the risk for gestational diabetes in obese women.

Potentially reducing labor length is just one more reason for women of size to exercise during pregnancy. It's a low-tech intervention that is very unlikely to harm (barring the rare contraindications to exercise in pregnancy) and seems likely to be helpful.

If exercising is something you already do, good work! Keep it up. Regularity of exercise is more important in pregnancy than its intensity. You don't have to run marathons to benefit. Just get out and move most days of the week.

If exercise is something you can improve on, get started. Choose a form of exercise that you enjoy. Walking, swimming, dancing, prenatal yoga, riding an exercise bike, and water aerobics are all forms of exercise that are very friendly to pregnant women of size. And remember, any amount you do is better than none.

You'll feel better for having exercised, trust me (I definitely felt better in my pregnancies when I exercised). And maybe it will pay off with a shorter labor, fewer complications, or less chance of a cesarean too.


Reference

J Sports Med Phys Fitness. 2015 Nov 12. [Epub ahead of print] Impact of physical activity during pregnancy on obstetric outcomes in obese women. Tinius R1, Cahill AG, Cade WT. PMID: 26564274

AIM: Maternal obesity is associated with complications and adverse outcomes during the labor and delivery process. In pregnant women with a healthy body weight, maternal physical activity during pregnancy is associated with better obstetric outcomes; however, the effect of maternal physical activity during pregnancy on obstetric outcomes in obese women is not known. The purpose of the study was to determine the influence of self-reported physical activity levels on obstetric outcomes in pregnant obese women. METHODS: A retrospective chart review was performed on 48 active obese women and 48 inactive obese women (N=96) who received prenatal care and delivered at the medical center during the past five years. Obstetric and neonatal outcomes were compared between the active and inactive groups. RESULTS: Obese women who were active during pregnancy spent less total time in labor (13.4 hours vs. 19.2 hours, p=0.048) and were less likely to request an epidural (92% vs. 100%, p=0.04). When stratified by parity, active multiparous women spent significantly less total time in labor compared to inactive multiparous (6.2 hours vs. 16.7 hours, p=0.018). There were no statistical differences between groups in rates of cesarean deliveries or neonatal outcomes. CONCLUSION: Maternal physical activity during pregnancy appears to improve obstetric outcomes in obese women, and this improvement may be more pronounced among multiparous women. Our finding is of particular importance as pregnant obese women are at higher risk for adverse and delivery outcomes.

Exercise During Pregnancy May Cut Cesarean Risk

Image from World Obesity Federation Image Bank*

I'm a big fan of being proactive in pregnancy. I think eating healthfully, getting enough sleep, avoiding stress when possible, and getting regular exercise strongly benefit pregnant women of all sizes. Now there is new research suggesting it may also lower the risk for cesarean.

However, keep in mind that there are plenty of women who don't do these things and still have a vaginal birth. And there are plenty of women who do everything "right" and still end up with a cesarean. There's certainly not a one-to-one relationship between exercise and cesareans. But being as proactive as possible in your health habits during pregnancy may lessen the risk for complications or for an unplanned cesarean.

Personally, in my first pregnancy I didn't exercise that much. I had quite a bit of bleeding and spotting at first and was told not to do much, plus we had a major move in the middle of it all which meant that most of my non-work time was spent on packing and unpacking from the move. I felt pretty out of shape by the end of pregnancy.

In my second and third pregnancies, I exercised quite a bit. I wasn't running marathons or anything, but I did walk regularly, and added in swimming, water aerobics, and prenatal yoga as my schedule allowed. If all else failed, I ran the stairs in my house. I felt SO much better and had way more stamina.

In my fourth pregnancy, I was taking care of my seriously ill mother as well as my three young children. It was hard to find time to sleep, let alone exercise, but I did still manage to walk some. I fit in swimming or stairs where I could but I didn't get nearly as much exercise as the second and third pregnancies. By the end, I felt the difference.

Here is the abstract for a recent study that supports the idea that regular exercise in pregnancy might cut the risk for cesarean. 

For me, exercise didn't make much difference in which pregnancies ended in cesarean, but it sure did make a difference in how I felt by the end of pregnancy! And I think it helped me lower my risk for complications like blood pressure issues etc., which I never got despite being "morbidly obese" and a much older mom.

So I'm a major fan of getting regular exercise in pregnancy. It doesn't have to mean running a marathon, but simply doing regular movement of some sort seems to be a common-sense thing to do. And if it lowers your risk for cesarean somewhat, all the better.

However, exercise programs are often pushed mainly for "obese" women. Frankly, ALL pregnant women should be encouraged to get more exercise, not just women of size. High-BMI women may benefit the most from it, but women of all sizes benefit from regular exercise.

As long as you don't have any medical contraindications, exercise is just a common-sense thing to do in pregnancy.


*Isn't it telling that I couldn't find a good positive picture of a pregnant woman of size exercising? Many of us do it, so why aren't there many good pictures of that? The very few pictures I did find were problematic for various reasons. Most images in articles about exercise for heavier pregnant women actually showed pregnant women of average size, or the images were patronizing and stigmatizing. Please, if you have a good picture of yourself pregnant and exercising, I'd appreciate it if you shared it with me for use in the future. 


Reference

Am J Obstet Gynecol. 2016 Aug 23. pii: S0002-9378(16)30579-8. doi: 10.1016/j.ajog.2016.08.014. [Epub ahead of print] Exercise during pregnancy and risk of cesarean delivery in nulliparous women: a large population-based cohort study. Owe KM1, Nystad W2, Stigum H2, Vangen S3, Bø K4. PMID: 27555317

...OBJECTIVE: The purpose of this study was to investigate the association between exercise during pregnancy and cesarean delivery, both acute and elective, in nulliparous women. STUDY DESIGN: We conducted a population-based cohort study that involved 39,187 nulliparous women with a singleton pregnancy who were enrolled in the Norwegian Mother and Child Cohort Study between 2000 and 2009. All women answered 2 questionnaires in pregnancy weeks 17 and 30. Acute and elective cesarean delivery data were obtained from the Medical Birth Registry of Norway. Information on exercise frequency and type was assessed prospectively by questionnaires in pregnancy weeks 17 and 30...RESULTS: The total cesarean delivery rate was 15.4% (n=6030), of which 77.8% (n=4689) was acute cesarean delivery. Exercise during pregnancy was associated with a reduced risk of cesarean delivery, particularly for acute cesarean delivery...The largest risk reduction was observed for acute cesarean delivery among women who exercised >5 times weekly during weeks 17 (-2.2%) and 30 (-3.6%) compared with nonexercisers (test for trend, P<.001). Reporting high impact exercises in weeks 17 and 30 was associated with the greatest reduction in risk of acute cesarean delivery (-3.0% and -3.4%, respectively). CONCLUSION: Compared with nonexercisers, regular exercise and high-impact exercises during pregnancy are associated with reduced risk of having an acute cesarean delivery in first-time mothers.

Placenta Accreta Rates Reflect High Cesarean Rates and VBAC Bans

October is Accreta Awareness Month. The International Cesarean Awareness Network (ICAN) is featuring Accreta Awareness as part of its focus this month, and is promoting the importance of donating blood in order to help women who experience accretas.

Placenta Accreta is a condition in which the placenta attaches too deeply to the uterine wall, or actually grows into the uterine wall. Occasionally it even grows through the uterine wall and into adjoining tissues. This means the placenta can't separate during birth. It causes massive bleeding, and frequently requires a hysterectomy in order to control the bleeding. Placenta Accreta has about a 7% maternal mortality rate and is one of the most serious obstetric situations a woman can face.

You can read more about Placenta Accreta in my series about it here:

• Part One: What Is Accreta?
• Part Two: Life-Threatening Complication of Prior Cesarean
• Part Three: Risks to Mother and Baby
• Part Four: Diagnosis, Treatment, and a Cautionary Story

Accretas have several different risk factors, including maternal age, parity, smoking, infection, pregnancy after fertility treatment, and prior uterine procedures such as D&C or fibroid removal.

However, the strongest risk factor for accretas is a history of prior cesarean sections. The discovery of placenta previa (a low-lying placenta) in a woman with a history of prior cesareans is particularly predictive of an accreta.

In addition, the risk for accreta rises strongly as the number of prior cesareans increases. Silver 2006 found the following risk for accreta by number of prior cesareans:

• First cesarean:                  0.24%
• Second cesarean:             0.31%
• Third cesarean:                0.57%
• Fourth cesarean:              2.13%
• Fifth cesarean:                 2.33%
• Sixth or more cesarean:   6.74%

A recent large Nordic study found:

The risk of AIP [abnormally invasive placenta] increased seven-fold after one prior caesarean section (CS) to 56-fold after three or more CS.

Accretas are associated with poor outcomes, but very high-order repeat cesareans are particularly associated with poor outcomes.

Many accretas occur in women who have a cesarean in their first pregnancy and are automatically scheduled for repeat cesareans thereafter. Women who have larger families are particularly impacted. Yet many of these women say that they were never counseled about the risk of accreta with repeat cesareans. This is wrong. Informed consent should include discussions of all the risks of both VBAC and repeat cesareans.

Alarmingly, the incidence of placenta accreta cases seems to be on the rise. As noted by ACOG in the graphic above, this is likely in response to the rising cesarean rates. This reflects an increase in both primary cesareans and routine repeat cesareans as a result of de facto VBAC bans.

The increase in accretas is not just a U.S. phenomenon. A recent study from Hong Kong, where there is a high underlying cesarean rate, demonstrates that the rate of accreta increased over time as the cesarean rate increased. The authors note:

The overall rate of morbidly adherent placenta...increased from 0.17/1000 births in 1999-2003 to 0.79/1000 births in 2009-2013.

For such a rare condition, that's a significant increase. A similar result was found in an Italian region with a strong increase in cesarean rates over the years. Researchers found that:

The incidence increased from 0.12% during the 1970s, to 0.31% during the 2000s. During the same period, cesarean section rates increased from 17 to 64%. Prior cesarean section was the only risk factor showing a significant concomitant rise. Our results reinforce cesarean section as the most significant predisposing condition for placenta accreta.

One recent analysis concluded:

The incidence of placenta accreta has increased 13-fold since the early 1900s and directly correlates with the increasing cesarean delivery rate.

Alarmingly, the increase in accreta rates also seems to parallel the rise in maternal mortality rates over time. There are many other factors that play into the maternal mortality rate, mind, but the high cesarean rate and resulting accretas is one major piece of the puzzle.

If we hope to reduce the number of women impacted by accretas, we must reduce the cesarean rate. The authors of the recent Nordic study pointed this out, saying:

Our findings indicate that a lower CS rate in the population may be the most effective way to lower the incidence of AIP [Abnormally Invasive Placenta]. 

This means not only reducing the number of women who have first cesareans but also the number of women who have automatic repeat cesareans. In order to do that, we must increase access to VBACs. Far too many women have difficulty finding providers who will support them in labor after cesarean. Many hospitals have outright VBAC bans.

Of course, it's only fair to note that most women who have higher-order cesareans will not experience an accreta. However, accreta is such a serious and life-threatening condition that even relatively small incidences carry a huge burden of complications, cost, and potential loss of life. That's why it is vital that women have balanced risk counseling after a prior cesarean and real access to VBAC if they want it.

There are many birth stories online of women who have experienced accretas. It's important to emphasize that many of them have good outcomes, but also important to point out that many of them have challenging outcomes, and some of them have even had tragic outcomes.

This is the bottom line. Real women have died because of accretas, leaving their children motherless. Others have lost their uterus to hysterectomy or their babies to prematurity. Although I have not personally known anyone who died from accreta, I have known several women who have had very close near-misses due to accreta. Nearly all lost their uteri as a result of their accreta, and some lost their babies as well.

This is the real consequence of a too-high cesarean rate. This is why it's so important to avoid non-indicated cesareans and improve VBAC access. 

*If you can, give blood to help support women who have been affected by accreta. 


References

Support Groups

• http://www.hopeforaccreta.org/
• https://www.facebook.com/hopeforaccreta/
• http://www.circleofmoms.com/survivors-of-placenta-accreta-increta-or-percreta 
• http://community.babycentre.co.uk/groups/a3859975/placenta_accreta_support

Accreta Studies

Semin Perinatol. 2012 Oct;36(5):315-23. doi: 10.1053/j.semperi.2012.04.013. Implications of the first cesarean: perinatal and future reproductive health and subsequent cesareans, placentation issues, uterine rupture risk, morbidity, and mortality. Silver RM. PMID: 23009962

Rates of cesarean delivery have substantially increased worldwide during the past 30 years. Indeed, almost one-third of deliveries in the United States are cesareans. Most cesareans are safe, and major complications are uncommon. However, there is a "concealed" downside to cesarean deliveries. There are rare but life-threatening morbidities that may occur, which are often overlooked because most cesareans go well. In addition, subsequent pregnancies are fraught with an increased risk of both maternal and fetal complications. The worst of these are associated with placental problems such as previa, abruption, and accreta. The risk dramatically worsens in patients with multiple repeat cesarean deliveries. This article will summarize and highlight the implications of the rising cesarean rate on maternal and fetal morbidity and mortality.

Hong Kong Med J. 2015 Dec;21(6):511-7. doi: 10.12809/hkmj154599. Epub 2015 Nov 6. Rising incidence of morbidly adherent placenta and its association with previous caesarean section: a 15-year analysis in a tertiary hospital in Hong Kong. Cheng KK1, Lee MM1. PMID: 26554269

OBJECTIVES: To identify the incidence of morbidly adherent placenta in the context of a rising caesarean delivery rate within a single institution in the past 15 years, and to determine the contribution of morbidly adherent placenta to the incidence of massive postpartum haemorrhage requiring hysterectomy. SETTING: A regional obstetric unit in Hong Kong. PATIENTS: Patients with a morbidly adherent placenta with or without previous caesarean section scar from 1999 to 2013. RESULTS: A total of 39 patients with morbidly adherent placenta were identified during 1999 to 2013. The overall rate of morbidly adherent placenta was 0.48/1000 births, which increased from 0.17/1000 births in 1999-2003 to 0.79/1000 births in 2009-2013. The rate of morbidly adherent placenta with previous caesarean section scar and unscarred uterus also increased significantly. Previous caesarean section (odds ratio=24) and co-existing placenta praevia (odds ratio=585) remained the major risk factors for morbidly adherent placenta. With an increasing rate of morbidly adherent placenta, more patients had haemorrhage with a consequent increased need for peripartum hysterectomy. No significant difference in the hysterectomy rate of morbidly adherent placenta in caesarean scarred uterus (19/25) compared with unscarred uterus (8/14) was noted. This may have been due to increased detection of placenta praevia by ultrasound and awareness of possible adherent placenta in the scarred uterus, as well as more invasive interventions applied to conserve the uterus. CONCLUSION: Presence of a caesarean section scar remained the main risk factor for morbidly adherent placenta. Application of caesarean section should be minimised, especially in those who wish to pursue another future pregnancy, to prevent the subsequent morbidity consequent to a morbidly adherent placenta, in particular, massive postpartum haemorrhage and hysterectomy.

Acta Obstet Gynecol Scand. 2013 Apr;92(4):457-60. doi: 10.1111/aogs.12080. Placenta accreta: incidence and risk factors in an area with a particularly high rate of cesarean section. Morlando M, Sarno L, Napolitano R, Capone A, Tessitore G, Maruotti GM, Martinelli P. PMID: 23347183

...The aim of this study was to investigate the change in the incidence of placenta accreta and associated risk factors along four decades, from the 1970s to 2000s, in a tertiary south Italian center. We analyzed all cases of placenta accreta in a sample triennium for each decade. The incidence increased from 0.12% during the 1970s, to 0.31% during the 2000s. During the same period, cesarean section rates increased from 17 to 64%. Prior cesarean section was the only risk factor showing a significant concomitant rise. Our results reinforce cesarean section as the most significant predisposing condition for placenta accreta.

Obstet Gynecol. 2015 Sep;126(3):654-68. doi: 10.1097/AOG.0000000000001005. Abnormal Placentation: Placenta Previa, Vasa Previa, and Placenta Accreta. Silver RM1. PMID: 26244528

Placental disorders such as placenta previa, placenta accreta, and vasa previa are all associated with vaginal bleeding in the second half of pregnancy. They are also important causes of serious fetal and maternal morbidity and even mortality. Moreover, the rates of previa and accreta are increasing, probably as a result of increasing rates of cesarean delivery, maternal age, and assisted reproductive technology....

BJOG. 2016 Jul;123(8):1348-55. doi: 10.1111/1471-0528.13547. Epub 2015 Jul 29. Abnormally invasive placenta-prevalence, risk factors and antenatal suspicion: results from a large population-based pregnancy cohort study in the Nordic countries. Thurn L, Lindqvist PG, Jakobsson M, Colmorn LB, Klungsoyr K, Bjarnadóttir RI, Tapper AM, Børdahl PE, Gottvall K, Petersen KB,Krebs L, Gissler M, Langhoff-Roos J, Källen K. PMID: 26227006

OBJECTIVE: The objective was to investigate prevalence, estimate risk factors, and antenatal suspicion of abnormally invasive placenta (AIP) associated with laparotomy in women in the Nordic countries. DESIGN: Population-based cohort study. SETTING AND POPULATION: A 3-year Nordic collaboration among obstetricians to identify and report on uterine rupture, peripartum hysterectomy, excessive blood loss, and AIP from 2009 to 2012 The Nordic Obstetric Surveillance Study (NOSS). METHODS: In the NOSS study, clinicians reported AIP cases from maternity wards and the data were validated against National health registries. MAIN OUTCOME MEASURES: Prevalence, risk factors, antenatal suspicion, birth complications, and risk estimations using aggregated national data. RESULTS: A total of 205 cases of AIP in association with laparotomy were identified, representing 3.4 per 10 000 deliveries. The single most important risk factor, which was reported in 49% of all cases of AIP, was placenta praevia. The risk of AIP increased seven-fold after one prior caesarean section (CS) to 56-fold after three or more CS. Prior postpartum haemorrhage was associated with six-fold increased risk of AIP (95% confidence interval 3.7-10.9). Approximately 70% of all cases were not diagnosed antepartum. Of these, 39% had prior CS and 33% had placenta praevia. CONCLUSION: Our findings indicate that a lower CS rate in the population may be the most effective way to lower the incidence of AIP. Focused ultrasound assessment of women at high risk will likely strengthen antenatal suspicion. Prior PPH is a novel risk factor associated with an increased prevalence of AIP.

Am J Obstet Gynecol. 2015 Sep;213(3):384.e1-11. doi: 10.1016/j.ajog.2015.05.002. Epub 2015 May 5. Morbidity associated with cesarean delivery in the United States: is placenta accreta an increasingly important contributor? Creanga AA, Bateman BT, Butwick AJ, Raleigh L, Maeda A, Kuklina E, Callaghan WM. PMID: 25957019

OBJECTIVE: The purpose of this study was to examine cesarean delivery morbidity and its predictors in the United States. STUDY DESIGN: We used 2000-2011 Nationwide Inpatient Sample data to identify cesarean deliveries and records with 12 potential cesarean delivery complications, including placenta accreta. We estimated cesarean delivery morbidity rates and rate changes from 2000-2011, and fitted Poisson regression models to assess the relative incidence of morbidity among repeat vs primary cesarean deliveries and explore its predictors. RESULTS: From 2000-2011, 76 in 1000 cesarean deliveries (97 in 1000 primary and 48 in 1000 repeat cesarean deliveries) were accompanied by ≥1 of 12 complications. The unadjusted composite cesarean delivery morbidity rate increased by 3.6% only among women with a primary cesarean delivery (P < .001); the unadjusted rate of placenta accreta increased by 30.8% only among women with a repeat cesarean deliveries (P = .025). The adjusted rate of overall composite cesarean delivery morbidity decreased by 1% annually from 2000-2011 (P < .001). Compared with women with a primary cesarean delivery, those women who underwent a repeat cesarean delivery were one-half as likely (incidence rate ratio, 0.50; 95% CI, 0.49-0.50) to experience a complication, but 2.13 (95% CI, 1.98-2.29) times more likely to have a placenta accreta diagnosis. Both cesarean delivery morbidity and placenta accreta were positively associated with age >30 years, non-Hispanic black race/ethnicity, the presence of a chronic medical condition, and delivery in urban, teaching, or larger hospitals. CONCLUSION: Overall, cesarean delivery morbidity declined modestly from 2000-2011, but placenta accreta became an increasingly important contributor to repeat cesarean delivery morbidity. Clinicians should maintain a high index of suspicion for abnormal placentation and make adequate preparations for patients who need cesarean deliveries.

BJOG. 2013 Jan;120(1):85-91. doi: 10.1111/1471-0528.12010. Epub 2012 Oct 24. Multiple repeat caesarean section in the UK: incidence and consequences to mother and child. A national, prospective, cohort study. Cook JR1, Jarvis S, Knight M, Dhanjal MK. PMID: 23095012

OBJECTIVE: To estimate the incidence of multiple repeat caesarean section (MRCS) (five or more) in the UK and to describe the outcomes for women and their babies relative to women having fewer repeat caesarean sections. DESIGN: A national population-based prospective cohort study using the UK Obstetric Surveillance System (UKOSS). SETTING: All UK hospitals with consultant-led maternity units. POPULATION: Ninety-four women having their fifth or greater MRCS between January 2009 and December 2009, and 175 comparison women having their second to fourth caesarean section. METHODS: Prospective cohort and comparison identification through the UKOSS monthly mailing system. MAIN OUTCOME MEASURES: Incidence, maternal and neonatal complications. Relative risk, unadjusted (OR) and adjusted (aOR) odds ratio estimates. RESULTS: The estimated UK incidence of MRCS was 1.20 per 10 000 maternities [95% confidence interval (CI), 0.97-1.47]. Women with MRCS had significantly more major obstetric haemorrhages (>1500 ml) (aOR, 18.6; 95% CI, 3.89-88.8), visceral damage (aOR, 17.6; 95% CI, 1.85-167.1) and critical care admissions (aOR, 15.5; 95% CI, 3.16-76.0), than women with lower order repeat caesarean sections. These risks were greatest in the 18% of women with MRCS who also had placenta praevia or accreta. Neonates of mothers having MRCS were significantly more likely to be born prior to 37 weeks of gestation (OR, 6.15; 95% CI, 2.56-15.78) and therefore had higher rates of complications and admissions. CONCLUSIONS: MRCS is associated with greater maternal and neonatal morbidity than fewer caesarean sections. The associated maternal morbidity is largely secondary to placenta praevia and accreta, whereas higher rates of preterm delivery are most likely a response to antepartum haemorrhage.

Obstet Gynecol. 2011 Sep;118(3):687-90. doi: 10.1097/AOG.0b013e318227b8d9. The rising cesarean delivery rate in America: what are the consequences? Blanchette H1. PMID: 21860302

Cesarean delivery is now the most common operation in the United States, and it has increased dramatically from 5.8% in 1970 to 32.3% in 2008. This rise has not resulted in significant improvement in neonatal morbidity or maternal health. Three recent studies of elective repeat cesarean deliveries performed before 39 completed weeks of gestation have demonstrated increased respiratory and other adverse neonatal outcomes. Maternal mortality in the United States has increased from 10 per 100,000 to 14 per 100,000 from 1998 to 2004. Contributing to this in an increasing incidence of placenta accreta associated with multiple uterine scars requiring the need for emergency cesarean hysterectomy, blood transfusion, and maternal mortality due to obstetric hemorrhage. To reverse the trend of the rising cesarean delivery rate, obstetricians must reduce the primary rate and avoid the performance of a uterine incision unless absolutely necessary for fetal or maternal indications. For women with one previous low transverse cesarean delivery, obstetricians should promote a trial of labor after previous cesarean delivery in those women who desire three or more children.

Staples vs. Sutures During Cesareans in High BMI Women

Women of size have higher rates of cesareans in many studies. Many of them are probably preventable but the fact remains that high-BMI women have a high rate of cesareans.

One of the problems with this is that "obese" women are at increased risk for infection and wound complications after a cesarean, and this leads to a great deal of morbidity and healthcare costs.

What can be done to improve outcomes? Past research has strongly suggested that closing the subcutaneous fat layer and avoiding a surgical drain reduces the rates of infection in high-BMI women. Higher doses of antibiotics also seem to be helpful, though the best dosage is still being debated. Using low transverse incisions instead of vertical incisions whenever possible probably also lowers the risk for complications.

Now, new studies seem to suggest that taking the time to suture the wound closed may result in less infection than using staples to close the wound. 

Doctors don't always like to do this because suturing takes longer. And suturing a woman with a lot of abdominal fat is more challenging as well. So most often, staples are used to close a cesarean, especially in women of size. But is this a good idea?

Mackeen 2015 performed a meta-analysis of studies and found that using sutures cut the risk for wound complications in half compared to staples. This risk reduction persisted even when data was stratified by obesity levels.

Zaki 2016 studied sutures vs. staples specifically in obese women. They found:

Women with staples had higher wound complications compared with sutures (22.0% versus 9.7%) with a 2.27 unadjusted relative risk (RR) (95% confidence interval (CI), 1.7 to 3.0) and 1.78 adjusted RR (95% CI, 1.27 to 2.49) after controlling for confounders in the final analysis, including vertical skin incisions. 

Further studies done specifically on high-BMI women should be done to confirm these findings, but the findings so far seem pretty clear. Using a subcuticular suture to close the incision seems to lessen the risk for wound complications compared to staples.

This is important news because research shows that as BMI increases, doctors are less inclined to use sutures. 

In other words, without intending to, doctors may actually be unnecessarily increasing the risk for wound complications after cesarean in women of size.

Conclusion

I'm glad to see that more research is FINALLY being done on how to lessen the rate of complications in women of size who undergo a cesarean.

For years, doctors simply made assumptions about what they thought would improve cesarean outcomes in obese women ─ but they didn't test their assumptions. Once they started testing the assumptions, they found a few surprises.

Doctors have traditionally been more inclined to use vertical incisions in high-BMI women. They did this because they thought that vertical incisions would lessen the risk for infection by avoiding the area underneath the belly (pannus). They were wrong; most research shows that vertical incisions actually increase the risk for wound complications in obese women.

They thought surgical drains would allow fluids to exit and thereby decrease the chances for wound separations and infections. Yet some research seems to suggest that surgical drains actually increase the risk for problems.

They assumed that the standard antibiotic dosage for all women was sufficient for high-BMI women too. Yet research shows that standard dosages probably do not provide adequate coverage to prevent infections.

When a cesarean is truly needed, it's a wonderful and life-saving thing to have available. Although cesareans carry more risks for obese women, there are important things that doctors can do to improve outcomes in high-BMI women when a cesarean is truly necessary. This list may now include suturing instead of using staples to close the wound, even if it takes slightly longer to accomplish.

However, let's not lose sight of the fact that the most important step that doctors can take to improve outcomes in obese women is to only do cesareans when they are truly needed. 


References

J Perinatol. 2016 Oct;36(10):819-22. doi: 10.1038/jp.2016.89. Epub 2016 Jun 2. Wound complications in obese women after cesarean: a comparison of staples versus subcuticular suture. Zaki MN, Truong M, Pyra M, Kominiarek MA, Irwin T. PMID: 27253895

OBJECTIVE: To compare wound complications between staples versus subcuticular suture for skin closure in obese women (body mass index (BMI)⩾30 kg m(-2)) after cesarean delivery (CD). STUDY DESIGN: We conducted a retrospective cohort study to compare wound complications between staples and subcuticular suture closure in women, with a prepregnancy BMI⩾30 kg m(-2) after CD between 2006 and 2011 at an inner-city teaching hospital. Wound complication was defined as a composite of wound disruption (hematoma or seroma) or infection diagnosed up to 6 weeks postpartum. Variables collected include age, parity, prior CDs, prior abdominal surgeries, incision type, chorioamnionitis, maternal comorbidities (hypertension, diabetes) and gestational age. RESULTS: Of the 1147 women included in the study, women with staple closure were older and had higher BMIs (40.6±9.3 versus 36.1±5.4) and were more likely to be multiparous, have a prior CD, diabetes and hypertension compared with women with subcuticular suture. The overall occurrence of wound complications was 15.5% (178/1147). Women with staples had higher wound complications compared with sutures (22.0% versus 9.7%) with a 2.27 unadjusted relative risk (RR) (95% confidence interval (CI), 1.7 to 3.0) and 1.78 adjusted RR (95% CI, 1.27 to 2.49) after controlling for confounders in the final analysis, including vertical skin incisions. CONCLUSIONS: In obese women, skin closure with staples at the time of CD is associated with a higher rate of wound complications compared with subcuticular suture. Skin closure with subcuticular suture over staples should be considered in obese women undergoing a CD regardless of skin incision type.

Am J Obstet Gynecol. 2015 May;212(5):621.e1-10. doi: 10.1016/j.ajog.2014.12.020. Epub 2014 Dec 19. Suture versus staples for skin closure after cesarean: a metaanalysis. Mackeen AD, Schuster M, Berghella V. PMID: 25530592

OBJECTIVE: We sought to perform a metaanalysis to synthesize randomized clinical trials of cesarean skin closure by subcuticular absorbable suture vs metal staples for the outcomes of wound complications, pain perception, patient satisfaction, cosmesis, and operating time...RESULTS: Twelve randomized trials with data for the primary outcome on 3112 women were identified. Women whose incisions were closed with suture were significantly less likely to have wound complications than those closed with staples (risk ratio, 0.49; 95% confidence interval [CI], 0.28-0.87). This difference remained significant even when wound complications were stratified by obesity. The decrease in wound complications was largely due to the lower incidence of wound separations in those closed with suture (risk ratio, 0.29; 95% CI, 0.20-0.43), as there were no significant differences in infection, hematoma, seroma, or readmission. There were also no significant differences in pain perception, patient satisfaction, and cosmetic assessments between the groups. Operating time was approximately 7 minutes longer in those closed with suture (95% CI, 3.10-11.31). CONCLUSION: For patients undergoing cesarean, closure of the transverse skin incision with suture significantly decreases wound morbidity, specifically wound separation, without significant differences in pain, patient satisfaction, or cosmesis. Suture placement does take 7 minutes longer than staples.

Am J Perinatol. 2014 Apr;31(4):299-304. doi: 10.1055/s-0033-1348402. Epub 2013 Jun 13. Maternal obesity and risk of postcesarean wound complications. Conner SN, Verticchio JC, Tuuli MG, Odibo AO, Macones GA, Cahill AG. PMID: 23765707

OBJECTIVE: To estimate the effect of increasing severity of obesity on postcesarean wound complications and surgical characteristics. STUDY DESIGN: We performed a retrospective cohort study of consecutive cesarean deliveries at a tertiary care facility from 2004 to 2008. Four comparison groups were defined by body mass index (BMI; kg/cm2): < 30 (n = 728), 30 to 39.9 (n = 1,087), 40 to 49.9 (n = 428), or ≥ 50 (n = 201). The primary outcome was wound complication, defined as wound disruption or infection within 6 weeks postoperatively. Surgical characteristics were compared between groups including administration of preoperative antibiotics, type of skin incision, estimated blood loss (EBL), operative time, and type of skin closure. RESULTS: Of the 2,444 women with complete follow-up data, 266 (10.9%) developed a wound complication. Compared with nonobese women (6.6%), increasing BMI was associated with an increased risk of wound complications: BMI 30.0 to 39.9, 9.2%, adjusted odds ratio (aOR) 1.4 (95% confidence interval [CI] 0.99 to 2.0); BMI 40.0 to 49.9, 16.8%, aOR 2.6 (95% CI 1.7 to 3.8); BMI ≥ 50, 22.9%, aOR 3.0 (95% CI 1.9 to 4.9). Increasing BMI was also associated with increased rates of midline vertical incision, longer operative time, higher EBL, and lower rates of subcuticular skin closure. CONCLUSION: A dose-response relationship exists between increasing BMI and risk of postcesarean wound complications. Increasing obesity also significantly influences operative outcomes.

Decreasing Cesarean Wound Complications in Obese Women

Best Pract Res Clin Obstet Gynaecol. 2015 Apr;29(3):406-14. doi: 10.1016/j.bpobgyn.2014.08.009. Epub 2014 Oct 16. Obesity and the challenges of caesarean delivery: prevention and management of wound complications. Ayres-de-Campos D1. PMID: 25457856

Caesarean section in obese patients is associated with an increased risk of surgical wound complications, including haematoma, seroma, abscess and dehiscence. This review focusses on the available strategies to decrease wound complications in this population, and on the clinical management of these situations. Appropriate dose of prophylactic antibiotics, closure of the subcutaneous tissue, and avoidance of subcutaneous drains reduce the incidence of wound complications associated with caesarean section in obese patients. For treatment of superficial wound infection associated with dehiscence, there are data from general surgery patients to suggest that the use of vacuum-assisted devices leads to faster healing and that surgical reclosure is preferable to healing by secondary intention, when there are no signs of ongoing infection. There is a need for stronger evidence regarding the prevention and management of wound complications for caesarean section in obese women.