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 However, most of the time, its use in fat women springs from outdated and non evidence-based teachings that an incision under the belly (pannus) predisposes the wound to infection, and that a vertical incision will supposedly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.

News Flash: Labor Managed Differently in High-BMI Women!

For a long time, doctors have observed a higher cesarean rate in high-BMI women, but always blamed this solely on obesity.

But how would obesity impede labor and result in more cesareans, you ask?

The usual reasons given (based on assumptions or poor research) were soft tissue dystocia (i.e., the fat vagina theory), or inefficient uterine contractility due to high leptin or cholesterol levels (seriously, that's a current theory still floating around, despite evidence that contradicts it).

Yet no one was asking whether the way labor was managed in "obese" women contributed to this high cesarean rate.

Now, for the first time, FINALLY someone is starting to ask these questions!  A Canadian study out earlier this year examined labor management of obese women compared with other women.

And guess what?!  As I've been saying for years, they found that the labors of women of size are indeed managed differently, with more interventions and a much lower threshold for surgery. 

Furthermore, when the study controlled for the use of interventions, the relationship between obesity and cesareans was "markedly attenuated." 

Details from the Study

There are a couple of interesting items in the study worth a closer look.

Induction Rates

First, induction rates went up strongly as BMI increased.  Here's a summary of induction rates by BMI category (delivery BMI):

• "Normal" BMI (20-24.9)               23.7% induced
• "Overweight" BMI (25-29.9)         29.3% induced
• "Obese" BMI (30-39.9)                37.2% induced
• "Morbidly Obese" BMI (40+)       50.0% induced

Now, some of that increased rate is to be expected, given that fatter women have higher rates of pre-eclampsia and other complications, and induction is more common in women with these complications.  But even so, a 50% induction rate?  Do 50% of all "morbidly obese" women really need to be induced? Come on!

A great deal of research has shown that induction of labor is linked to higher cesarean rates.  This is particularly true for first-time mothers or women who have never had a vaginal birth before, or whose cervix was not ripe before the induction.

So why don't any researchers (including this one) connect the dots between such an extremely high induction rate in women of size and a resulting high cesarean rate?

The authors don't really comment on the induction rates or question them at all; most research never does.  Most authors assume that all these inductions are truly indicated, especially in women of size.  But frankly, they need to question such a high rate of induction more closely.

How many of these inductions were for real medical indications, and how many were for dubious indications like suspected macrosomia or provider fear? 

We know from research that inducing early for a suspected big baby does not improve outcomes, and actually strongly increases the cesarean rate in many studies.  Yet it is common practice still among clinicians to induce labor early if a big baby is suspected, especially in women of size. 

So when you see the 50% induction rate in "morbidly obese" women, how many were for "soft" indications like suspected macrosomia?  And what was the cesarean rate among those induced for "soft" indications? I would love for researchers to look more carefully at induction indications and how that influences cesarean rates in women of size.

We know from another recently published study that high induction rates definitely do have a strong influence on cesarean rates in obese women.  According to the authors of that study:

We conclude that morbid obesity is associated with a significantly higher risk of pre-existing medical conditions, developing antenatal complications, induction of labour, caesarean section and greater birth weight. However, there was no significant difference in caesarean section rates when adjusted for induction of labour. 

More research is needed to further clarify the impact of high induction rates on cesarean rates in obese women, and researchers need to finally start questioning the validity of many of these inductions.

Cervical Status Upon Admission

Another interesting finding that deserves further investigation is a major difference in cervical status upon admission and what might be influencing this.

Women whose cervix is more dilated upon admission tend to have shorter labors and a lower cesarean rate; those whose cervix is less dilated at admission usually have longer labors and more cesareans because their bodies aren't ready to labor yet. 

In this study, 37.9% of women of average BMI had minimal cervical dilation (2 cm or less) upon admission to the hospital.  In comparison, 55.7% of "morbidly obese" women had minimal cervical dilation upon admission.

Yes, this is surely partly due to a higher rate of inductions and therefore less spontaneous labors in the high-BMI group, but it also suggests that perhaps this group is far less ready for labor when being induced.  Again, many authors have noted this and have blamed it on "inefficient uterine contractility" or hormonal deficits, but what if there are other factors they are not considering?

Studies have shown that high-BMI women have longer menstrual cycles and longer gestations; perhaps what is happening is that their due dates are not being sufficiently adjusted for their longer cycle length and as a result, their bodies are less ready for labor when the doctors think they "should" be going into labor. And, as a result, they have more inductions, less cervical ripeness when induced, and more cesareans when the induction doesn't work.

More Interventions

The study found that there was more use of oxytocin augmentation and epidurals as BMI increased.  The pit augmentation increase may reflect the lower level of cervical ripeness before labor, but it may also reflect the common perception among some clinicians that obese women won't labor sufficiently on their own. So they automatically just start pitocin augmentation, without ever looking at whether it's needed or not.

The increased epidural rate may simply reflect the higher rate of inductions and pitocin augmentations; it's hard to go through such induced and augmented labors with little mobility and not need some pain relief.  However, it may also reflect the common practice of strongly encouraging early epidural placement in obese women to avoid a difficult placement later if a cesarean is needed.

(And of course, once that epidural is placed, oxytocin augmentation is often needed to compensate for the way that epidurals tend to slow labor.  It can be an vicious circle.)

Lower Surgical Threshold

The study also shows that doctors were quicker to terminate labor early and move to a cesarean in "obese" women.  In the study, the labors of "morbidly obese" women were terminated about an hour earlier than women of average BMI.

Some of this is understandable; surgery in a very heavy woman is more difficult and takes quite a bit longer than in a woman of average size.  Doctors want to avoid an emergency situation where every second counts to save a baby, and especially so in a woman whose extensive adipose layers may require more time to get to the baby in the first place.  Therefore, doctors may be more prone to intervene early in women of size, before things get to an emergency situation.

Yet most cesareans are not done under truly emergent conditions, and research shows that many women whose progress is slow are able to give birth vaginally if just given a little more time, and their babies generally do just as well.

So doctors have to walk a fine line between not waiting too late and not intervening too early.  From this study, it looks like too many doctors are erring on the side of intervening far too early.  And because cesareans are extra risky for women of size, this is a cause for concern ─ and a potentially modifiable variable for reducing the tremendously high cesarean rate in women of size.

Final Thoughts

As I've been saying for years, the high cesarean rate in obese women is not only about obesity itself, but also about the way that obese women are managed during pregnancy.

Sky-high induction rates, increased utilization of interventions during labor, and a very low threshold for surgical intervention all combine to ratchet up the cesarean rate in women of size.

The important thing to note is that these are all potentially modifiable factors for reducing the cesarean rate in this group.  

Up till now, the only options most doctors saw for lowering the cesarean rate in women of size involved  encouraging weight loss before pregnancy or restricting weight gain during pregnancy.  Yet this research suggests that if doctors simply change their management practices and fear levels around women of size, it's likely that the cesarean rate can be lowered in this group without draconian weight restrictions.

In the Canadian study, the authors concluded: 

Because of the potential morbidities associated with Caesarean section, we must modify our management approaches to allow equal opportunity for a vaginal birth for all women.

Those are strong words for an obstetrical community that's usually pretty mealy-mouthed about these things, and frankly, it's nice to finally hear them from someone other than me.  Bravo to these authors for being willing to advocate for vaginal birth for women of size at a time when some doctors are advocating pre-emptive cesareans across the board for this group.

But if doctors really want to get serious about allowing equal opportunity for a vaginal birth for fat women, first and foremost they need to crack down on the insanely high induction rates, as well as re-examining the use of interventions and threshold for surgery in this group.


References

J Obstet Gynaecol Can. 2011 May;33(5):443-8. Higher caesarean section rates in women with higher body mass index: are we managing labour differently? Abenhaim HA, Benjamin A.  PMID: 21639963

Background: Higher body mass index has been associated with an increased risk of Caesarean section. The effect of differences in labour management on this association has not yet been evaluated.

Methods: We conducted a cohort study using data from the McGill Obstetrics and Neonatal Database for deliveries taking place during a 10-year period. Women's BMI at delivery was categorized as normal (20 to 24.9), overweight (25 to 29.9), obese (30 to 39.9), or morbidly obese (≥ 40). We evaluated the effect of the management of labour on the need for Caesarean section using unconditional logistic regression models.

Results: Data were available for 11 922 women, of whom 2289 women had normal weight, 5663 were overweight, 3730 were obese, and 240 were morbidly obese. After adjustment for known confounding variables, increased BMI category was associated with an overall increase in the use of oxytocin and in the use of epidural analgesia, and with a decrease in use of forceps and vacuum extraction among second stage deliveries. 

Higher BMI was also found to be associated with earlier decisions to perform a Caesarean section in the second stage of labour. 

When adjusted for these differences in the management of labour, the increasing rate of Caesarean section observed with increasing BMI category was markedly attenuated (P less than 0.001). 

Conclusion: Women with an increased BMI are managed differently in labour than women of normal weight. This difference in management in part explains the increased rate of Caesarean section observed with higher BMI.

Aust N Z J Obstet Gynaecol. 2011 Apr;51(2):172-4. Impact of morbid obesity on the mode of delivery and obstetric outcome in nulliparous singleton pregnancy and the implications for rural maternity services. Green C, Shaker D.  PMID: 21466521

Obesity represents a rapidly emerging epidemic amongst pregnant women. Our study looks at the impact of morbid obesity on pregnant singleton nulliparous women in comparison with normal body mass index women. We conclude that morbid obesity is associated with a significantly higher risk of pre-existing medical conditions, developing antenatal complications, induction of labour, caesarean section and greater birth weight. However, there was no significant difference in caesarean section rates when adjusted for induction of labour. We also found no significant difference in length of hospital stay, postnatal complications and neonatal morbidity.

Increased Morbidity After Just One Cesarean

This study is about adverse outcomes in the next pregnancy after just one cesarean.  Women with only one prior cesarean were already at increased risk for anemia, placental abruption (where the placenta pulls away from the uterus before birth, cutting off nutrients and oxygen), uterine rupture, and hysterectomy.

Of course, the actual numerical risk of these complications is generally small, but it does represent an increased risk over women who first birth was vaginal, and that's an important point.

If 1 out of 3 women in the USA is having a baby via cesarean (and in some hospitals, the rate is more like 1 in 2 or more), that's an awful lot of potential risk being put onto women.  And that's after only one cesarean. Most women who have one cesarean will go on to have more with future children because VBAC is not an option in far too many hospitals.

When cesareans save lives, these risks are absolutely worth the trade-off.  When cesareans are used casually or for dubious indications, these trade-offs are much more ominous.

The authors' conclusion is that women who have cesareans need to be counseled about the possible increased risks in future pregnancies. This is true, but the importance of reducing these risks by avoiding that first cesarean whenever possible should also have been mentioned.

Recognizing that cesareans carry risks is an important part of the discussion of the public health implications of a high c-section rate.  



Am J Obstet Gynecol. 2011 Sep 24. [Epub ahead of print] Morbidity following primary cesarean delivery in the Danish National Birth Cohort. Jackson S, et al.   PMID: 22051815

Source: Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, CA. 

OBJECTIVE: Cesarean delivery rates are on the rise in many countries, including the United States. There is mounting evidence that cesarean delivery is associated with adverse reproductive outcomes in subsequent pregnancies. The purpose of this article is to review those outcomes in a well-defined cohort of pregnant women.
STUDY DESIGN: In a cohort of primigravid women from the Danish National Birth Cohort with known baseline exposure characteristics, we stratified women by method of first delivery, vaginal or cesarean, and evaluated for appearance of adverse reproductive events in subsequent pregnancies.
RESULTS: After adjusting for age, body mass index, alcohol, smoking, and socioeconomic status, women who underwent cesarean delivery at first birth were at increased risk in their subsequent pregnancy for anemia (odds ratio [OR], 2.8; 95% confidence interval [CI], 2.3-3.4), placental abruption (OR, 2.3; 95% CI, 1.5-3.6), uterine rupture (OR, 268; 95% CI, 65.6-999), and hysterectomy (OR, 28.8; 95% CI, 3.1-263.8).
CONCLUSION: Women who deliver their first baby with a cesarean are at increased risk of adverse reproductive outcomes in subsequent pregnancies and should be counseled accordingly.

Need an Extra Layer for Warmth?

If you are a person of size and a "cold" person ─ that is, strongly affected by cold weather and in need of lots of extra layers during the wintertime ─ then you know how hard it can be to find those extra layers in our sizes.  So let's talk about that for a minute.

As frequent readers know, I have hypothyroidism.  It's well-treated with meds, my TSH is in my ideal range, and I'm much less symptomatic than I used to be, but that doesn't mean I am totally symptom-free.

One of the most striking symptoms that remains is how poorly I regulate my temperature.  Within a certain range of temps, I'm fine, but even slightly outside that narrow range and I'm really uncomfortable.  In particular, I am strongly affected by cold.  It really makes me absolutely miserable, I kid you not.

So I'm always looking for extra layers to help keep me warmer in the winter...but I am a bit claustrophobic and hate feeling suffocated by really thick or poufy layers.  And I don't tolerate itchy fabrics like wool very well either.  In addition, even when there's good-quality stuff available, it's usually not available in my size.  Most plus-sized stuff in the athletic brands goes up to 2x or maybe 3x, but I typically prefer a 4x because I like things quite roomy and comfortable.  So it's not easy to find something that suits my needs very well.

Junonia makes exercise and outdoorwear in extended sizes (4x, 5x, sometimes 6x). I've bought from them for years but their quality is spotty.  Sometimes I get something really great from them (so they are definitely worth checking out), but sometimes I've gotten some very mediocre stuff too.  Generally speaking, they don't seem to have the kind of quality and choice of really good outdoor stuff that I could get at REI if I were of average size, like the really high-tech insulation-against-cold fabrics or the ultra-light packable gear, etc.  And I really want the good stuff.

I am not overly outdoorsy because of my cold-weather intolerance but I do have times when I do outdoorsy stuff.  I like to take walks in my area, and we have been known to camp or hike. I also volunteer at my kids' school, which regularly has "farm days" (for environmental education), no matter what the weather is...raining, windy, snowing, sleeting, you name it. That can be pretty brutal.  So I definitely need some layers and good outerwear for these activities.

Even around the house at night, it gets a lot colder than I am comfortable with, but I'm not willing to crank up the heat for the whole house that far when I'm the only one really affected. So, given how cold I tend to be, I need some good-quality layers for lounging around or working at home. I'm looking for lightweight but very warm layers ─ in my size ─ that I can add and subtract as needed.

Last year, I discovered that Columbia Sportswear carries good-quality sports and cold-weather clothing/gear in plus sizes.  They have women's sizes up to 3x, but their men's sizes go up to 4x and sometimes 5x.  This gives more choices to those of us who need/prefer extended sizes. (The men's sizes also have an option for "tall" sizes if you need that. I, alas, am very far from needing that.)

It frustrates me to have to shop in the men's department in order to get really good-quality sports and outdoor clothing in my size, but hey, at least we have some choices, even if it's in menswear.  So last year I invested in a whole bunch of winter gear from Junonia and Columbia, and have been testing it this year to see what's best.

I've fallen in love with the following item and wanted to let you know about it before it's all gone:

http://www.columbia.com/Men%E2%80%99s-Mountain-Tech%E2%84%A2-1/2-Zip-%E2%80%94-Big/AX6565,default,pd.html#

It's a lightweight polyester half-zip sports shirt for wicking away moisture while running or biking.  However, I've found that it does an amazing job of keeping me warmer, much better than a wool sweater or a cardigan.  I just wear normal clothes underneath, and put this on top whenever I start feeling chilly.

That's usually enough for hanging around the house, doing chores, driving in the car or for short jaunts outside if the weather's not too bad.  For longer outside jaunts in nasty weather, I wear them for layering under my winter coat (the soft shell coat or the Bugaboo parka from Columbia) as needed.

Sometimes if I'm really cold I will put on two of these zip-up sports shirts.  They are so lightweight that I don't feel like the Stay-Puft Marshmallow Man, and they really do add a nice layer of extra warmth.  I haven't found this combination of warmth and thinness of fabric with any other product, so I wanted to be sure to let you know about these before they are all gone.

These little zip-up sport shirts have made a MAJOR difference for me in staying warmer in and out of the house.  I still have cold moments, but these have really helped. They come in several different colors and pack really well, so they'd be ideal for trips too.

I'm buying some more to have on-hand.  I was hoping they'd be on sale after the holidays, but no such luck. So they're not cheap....about $40.....but well worth it in my book!

If you need some more stay-warm options, you might want to check them out.

Fourth Annual Turkey Awards: Leaps of Logic, the Dead Baby Card, and Scorched Earth Tactics

Well, it's that time of year again...time for my Fourth Annual Turkey Awards.

The Turkey Awards are my opportunity to highlight a biased or ignorant remark or media coverage of "obesity and pregnancy," a particularly insensitive treatment by a care provider towards a woman of size, or a trend in the care of women of size that is troubling and frustrating.

As always, I have plenty of candidates to choose from.  The hard part is limiting myself to just one.

Here's this year's nominee, another gem from My OB Said What.  I picked this one because it fails on several different levels:

“I am sure you have gestational diabetes because you are overweight, you need to be on Glucophage. If you are not comfortable taking that medication you will end up with a stillborn.”   – OB to mother, as found here

Sigh. This doctor may have meant well, but his statement has several things that demonstrate some of the troubling trends and perceptions around obesity and pregnancy, including:

• Jumping To Conclusions About Risks
• Scorched-Earth Tactics To Deal With Inflated Perception of Risk
• Pulling the Dead Baby Card To Ensure Compliance with Intervention.

Jumping To Conclusions About Risk

Okay, let's start with the obvious ─ the exaggeration of risk around obesity and pregnancy. We've discussed this before, but it always bears repeating because it's such a common issue.

The problem with the coverage of risk around obesity and pregnancy is that providers often start doing "mental inflation" of the actual numerical risk, and then they start making unfounded leaps of logic from there.

A statement with some truth to it, such as "Obese women are at increased risk for gestational diabetes," gets hyped in the press and in the research until it becomes transformed in some caregivers' minds into "Most obese women get gestational diabetes."  Then it's just a short jump to "Nearly all obese women get gestational diabetes" to "This obese woman no doubt ALREADY HAS gestational diabetes right now."

But the fact of the matter is that while the risk for gestational diabetes is definitely increased in women of size, most women of size still don't get GD.  You can cherrypick whatever study you want, but no study shows a 100% GD rate in obese women, even the most obese women.

Many studies show around a 15% risk for GD in "morbidly obese" women.  This is definitely higher than the 2-4% range found in a "normal BMI" population, but hardly universal.  What most providers fail to do is the opposite math.....that is, if 15% of morbidly obese women get GD, then that means that 85% do NOT.

Yes, that's right.....the majority of even very fat women will not get GD.

Are fat women at increased risk for getting GD?  Yes, absolutely.  Do all of them get it?  No, not even remotely close.  In fact, most do not get it.

And remember, just because a particular group is at increased risk for a complication does not mean that everyone in that group will get that complication, nor does it mean that you can predict the outcome for any individual within that group.

Of course, you can make a case for this being a rogue doctor, jumping to conclusions. Hopefully, most providers who care for women of size understand that GD is by no means a foregone conclusion in this group.  But I'm hearing stories like these more and more often.

There are a lot of care providers out there who have a distorted sense of risk around obese women and GD, from the ones who force their obese clients to undergo really frequent GD testing to those that push weight loss during pregnancy as a way to avoid GD (despite evidence that weight loss in pregnancy is risky).

So this comment is a candidate for this year's Turkey Award because of this individual doctor's mental inflation of risk ─ turning a mere potential of risk into an inevitable outcome in his mind.

But this comment also gets nominated because it's not just about this doctor's individual bias; it demonstrates an overall troubling trend of a distorted sense of risk about pregnancy in women of size.

Scorched Earth Tactics for Inflated Perception of Risk

Another issue I see in the comment is the kind of Scorched Earth, over-the-top tactics that some providers take in order to try to reduce the risks associated with obesity and pregnancy.  There is little research on these tactics, mind, but because care providers have such an exaggerated sense of risk around obese pregnancies, they feel justified in taking the Napalm Option...just in case.

For example, in the past, some care providers have advocated extremely restrictive diets for obese women in pregnancy.  Obese pregnant women have been put on 1200 calorie or even 1000 calorie diets during pregnancy, or told to drink Slim-Fast in order to limit their weight gain. Some are told that they have to lose weight during pregnancy....10, 20, even 50 pounds, during pregnancy.  It doesn't matter how this is achieved, the main goal is for them to lose weight in pregnancy, even if it sacrifices nutritional adequacy, since many care providers erroneously believe that fat women have extra nutritional stores to draw from instead.

This is the Napalm Option; resorting to extreme measures because you don't know what else to do or you are convinced that the risk is SOO high that only extreme measures will improve outcomes.

A new Scorched-Earth Tactic being considered is a move among some care providers to prophylactically prescribe metformin to all obese women during pregnancy in order to prevent big babies and other complications.

The use of Glucophage (metformin) in pregnancy is already somewhat controversial, even in women with strong indications for it (PCOS, severe insulin resistance, gestational diabetes). Its use prophylactically in all obese women, even those without other risk factors, should be even more controversial...yet many care providers are not questioning it at all.

Metformin is probably relatively safe during pregnancy for those with strong indications for it but some docs are very conservative about its use because the trials on it so far are small and some have found an increase in pre-eclampsia in women on metformin (while others have not). More data is needed.

Therefore, many docs err on the side of taking women off metformin during pregnancy, but there are a number of practices where the protocol is to continue metformin (with informed consent) because it lowers the risk for GD and possibly miscarriage and big babies as well.

I'm not opposed to the use of metformin in pregnancy in those for whom it is indicated and in those who have been given full informed consent.  They get to evaluate the research and decide for themselves whether they think it's a worthwhile intervention. However, I think across-the-board use of metformin on all obese women is highly questionable.

One early trial of metformin in pregnancy found an increase in both pre-eclampsia and stillbirth in the metformin group, so caution is clearly indicated.  [However, it has to be noted that there are two major confounding factors here. The women on metformin were mostly type 2 diabetics with pre-existing diabetes and poorer control; they also put these same women on 1200 calories a day, which might also be a factor.] Later trials have found no increase in stillbirth with metformin.

Another study of metformin vs. insulin for treatment of GD found a slightly higher rate of spontaneous-labor prematurity in the metformin group, although the confidence intervals were wide and crossed 1.0, so the trend could be attributable simply to chance.

Bottom line, we need more long-term data from larger groups on the safety of metformin during pregnancy in women with PCOS or GD, as well as the benefits and risks of metformin used in a wider population of women. Right now, the best data shows it lowers the risk for GD and miscarriage in women with PCOS, and probably does not increase the risk for birth defects. Other results vary from study to study. It’s probably a reasonably safe med for women with PCOS or GD, but we need more data to be sure.

Despite this, there is a trend to put ALL women of size on metformin prophylactically (there is a trial of this in the UK right now) and THAT I have problems with. It’s one thing to put a woman with severe PCOS or GD on this med, it’s entirely another to put all healthy high-BMI woman with no known glucose issues on it prophylactically. Ugh.

So this comment gets an individual nod for the Turkey Award because not only does the doctor assume the woman is automatically going to get gestational diabetes, he also wants to put her on metformin prophylactically, just on the basis of her being "overweight" (without proof of GD).

But it also gets a Disturbing Trend nod because it represents a new willingness among some care providers to prescribe extreme measures ─ like prescribing weight loss during pregnancy or putting all fat women on metformin ─ because of their inflated sense of risk around pregnancy in women of size.

Remember, the Napalm Option often harms more than it helps.  We must be cautious about being overly-interventive without proof that such interventions actually improve outcomes.

Pulling the Dead Baby Card to Ensure Compliance

Yet another problem highlighted by this quote is the issue of what we cynical activists call "The Dead Baby Card."

The Dead Baby Card is telling women in an emotionally manipulative way, your baby will die if you don't do exactly what I tell you.

(Its corollary is, And If You Question Me, You're A Bad Mother and Must Not Love Your Child.)

It's not merely informing a woman of the possibility of a poor outcome, it's medical bullying trying to force a woman (via scaring or shame or guilt etc.) to go along with a particular kind of highly interventive care the physician wants.

It's not a reasonable or sensible precaution in the face of an extremely high-risk situation, it's using the mother's fears to manipulate her into some dubious intervention the doctor wants, usually for his own convenience or fear of litigation.  And it's implying that the woman is a Bad Mother if she even thinks about questioning these interventions.

It's statements like, "We think your baby is going to be 9 lbs., so you have to have a planned cesarean or your baby will get stuck and die," even though research shows that elective cesareans for macrosomia do not improve outcome and may actually worsen it.

Or telling a woman that if she chooses Vaginal Birth After Cesarean, her baby will almost certainly die. And if the woman dares to question the provider, it's using scare tactics or implying that she's selfish to even consider such another choice. It's using emotionally manipulative language to bully a mother into following a questionable course of treatment the doctor wants.

In the Metformin example above, telling the mother that if she does not go along with the doctor's preferred treatment plan (i.e. use of metformin), her baby will probably die is medical bullying, a.k.a. Pulling The Dead Baby Card.  The doctor is trying to scare her into complying with his questionable intervention by using the biggest scare tactic he knows.

Instead, the mother should be counseled about the possibility of gestational diabetes, the pros and cons of GD testing, the small but real possibility for stillbirth if there was uncontrolled pre-existing diabetes, and offered GD testing.  She should be informed that some care providers are using Glucophage to prevent/treat GD, she should be informed of the pros and cons of metformin, and offered the choice to consider it.

She should not be ordered to take metformin, or told that if she doesn't take it her baby will undoubtedly die.  That's classic Dead Baby Card territory, and that's unethical and unconscionable medical bullying.

So this comment is a "winner" a third time because of this doctor trying to scare this mother into an extreme intervention by using emotional manipulation, and because it sadly represents a tactic that's being used against women of size far too often these days.

Medical bullying is being used far too often these days, and particularly against women of size.  This kind of over-the-top manipulation has to stop.

Final Thoughts

This comment is nominated for my Fourth Annual Turkey Award because it demonstrates an Epic Fail on several different levels.

It presumes an "overweight" woman will automatically get gestational diabetes (when most will not), it orders her to take metformin prophylactically just on the basis of her weight alone (without proof of GD), and tries to scare her into compliance by suggesting that her baby will die if she doesn't agree to this intervention.  It's a classic case of medical bullying.

Of course, we need to make it clear that most providers don't treat women of size like this.  And hopefully most would never result to medical bullying like this.

But this comment does represent several troubling trends in the care of women of size, including the tendency to Jump to Conclusions about Risks, the increasing use of Scorched-Earth Tactics, and the use of the Dead Baby Card to scare women of size into whatever extremist intervention the doctor wants to use on them.

And that's why this little comment gets this year's nomination for a Turkey of the Year Award.


*By the way, My OB Said What is looking for submissions on the idiotic things caregivers sometimes say to women.  If you have more doozies on things they say to fat pregnant women, I hope you will submit them so we can document this kind of treatment.


Do note, they also accept submissions for positive, helpful things caregivers say to women─it doesn't always have to be bad. If you have had a really supportive caregiver as a woman of size, be sure to nominate those stories too.  It's so important to highlight the positive stuff too!


Either way, email your story to submissions@myobsaidwhat.com

Dear Santa: Research on My Wish List

Dear Santa:

As I review the research on "obesity" and pregnancy, it always strikes me what's missing from this research.

Santa, since you are Patron of the Plus-Sized, I'd like to request some improvements as my Christmas gift this year. Could you whisper in some researchers' ears and plant the following suggestions?

Do More Meaningful Research

First, I'd like to request that researchers stop going for the easy publishing hits and start making their research more meaningful.  For example, most research on obesity and pregnancy now is just a litany of risks....fat women have more risk for "x" or "y" ─ but without any insight as to why they are more at risk for these things.  Study after study reiterating a litany of risks is not very meaningful anymore, but it does tend to ratchet up doctors' perceptions of risk around obesity, especially when they only use odds ratios instead of actual numerical risk.

I think it's well-established that women of size are more at risk for certain things....the question is what can we do about it. That's where our focus needs to be in obesity and pregnancy research right now; not just documenting increased risk but what to do about it.  And that leads us directly to the next item on my Dear Santa List.....

Research Improving Outcomes Without Weight Loss 

Without fail, nearly every study pushes weight loss as the answer to Life, the Universe, and Everything. Yet they stubbornly fail to connect the dots from other research that clearly shows that long-term weight loss is extremely unlikely, and that weight loss attempts often actually lead instead to further weight gain.   

If the only tool in our toolkit for improving outcome is one that is extremely unlikely to succeed, then it's time to develop some new tools in the toolkit.  We must start looking beyond weight loss as the only answer to improving outcomes.

Distinguish Between Correlation and Causation 

I would love to see more obesity research differentiate between correlation and causation when it comes to obesity.  Just because a certain outcome is associated with obesity does not mean obesity causes it (or that weight loss cures it).  In fact, a third factor common to both may actually be the cause...or some factor we don't understand yet.

I'd love to see researchers consider the possibility the obesity is a symptom of an underlying difference (in genetics, in metabolism, in hormonal issues, in ability to process insulin, etc.), rather than the automatic cause of problems.  If obesity is just another symptom, then focusing on weight loss is just a band-aid approach (and would explain why weight loss is often unsuccessful).  Focusing on the exact cause would lead to more improvement in outcomes long-term, which is what we really want, isn't it?

We have to move beyond our "blame the victim" mentality around obesity (i.e., obesity is a voluntary state caused mostly by bad behaviors), and start considering the possibility that obesity may often be simply another symptom of an underlying physical or metabolic difference.

Examine Interventions to See If They Improve Outcome

Many interventions to improve outcome have been proposed for women of size, especially "morbidly obese" women.  RCOG, the British version of ACOG, recommends that morbidly obese women be put on a low-dose aspirin regimen prophylactically to try and lower the rate of pre-eclampsia in this group.  The SOGC (Canadian version of ACOG) now recommends that morbidly obese women be put on regimens of ultra-high dose folic acid to try and lower the rate of birth defects in this group. Yet both of these recommendations were undertaken without research to show that they improve outcome, nor am I aware of any current studies looking to see if such regimens improve outcome.

Doctors often recommend care regimens in fat women in hopes that they will reduce poor outcomes, but without follow-up testing to see if these interventions improve outcome.  For example, as we recently discussed, doctors were taught for years that a vertical incision would lower the wound complication rate in very obese women, but when someone finally actually did a study of this question, they found that vertical incisions actually performed more poorly.

There's nothing wrong with proposing a potential intervention to see if it improves outcome in women of size (and prophylactic aspirin or high-dose folic acid may actually be a reasonable precaution for at least some very heavy women), but researchers have to then follow up and examine whether the proposed intervention actually improves outcomes or not.

Ideas for Specific Studies I'd Love To See

Antibiotic Dosing - In size acceptance circles, we've been saying for years that weight-based dosing may be needed to improve outcomes in people of size after surgery (depends on the type of antibiotic and its mechanism of action; some need weight-based dosing and some do not).  But we've consistently had difficulty in getting care providers to actually do this.

A recent study showed that 2 g of cefazolin given shortly before a planned cesarean did not reach minimal inhibitory concentration to knock out gram-negative bacteria in nearly half of morbidly obese women.  Since cefazolin is the antibiotic of choice in many surgical procedures (especially cesareans), it's time for a randomized controlled trial to find out what the optimal dosage for morbidly obese women actually is.

This shouldn't be that hard or that difficult a study to do; it's beyond me why it hasn't been done already. And it's vital that this be done, since chronically underdosing obese people may be adding to the increasing societal problem of antibiotic-resistant bugs, not to mention worsening outcomes among women of size.

Midwifery Model of Care - I'd love to see a study that specifically compared outcomes for obese women who experienced a low-intervention, "midwifery" model of care, vs. obese women who experienced a high-intervention, high-risk "bariatric obstetrics" model of care.  Research clearly shows that cesarean rates are lower for most women who experience a midwifery model of care, but there is no study that directly compares the two models of care specifically for obese women.

Given the strong move in many places to deny women of size the right to access low-intervention midwifery care ─ or even just regular obstetric care ─ and "alternative" options like waterbirth, birth centers, and homebirth, it behooves us to examine the which model of care actually improves outcomes better in this population.  What data we have and anecdotal stories suggest that the midwifery model will be advantageous for women of size who do not experience severe complications ─ but we need direct studies of the issue to confirm or deny that.

Fetal Malpositions - I'd love to see another modern study examine whether women of size have more malpositioned babies. Many very old studies mention a common perception that obese women have higher rates of malposition, and there is one modern study that confirms nearly twice the rate of posterior babies in obese women ─ but we really need more than that.  From the stories women have submitted to me (and from my own experiences), it seems like more women of size have malpositions, and this may be a prime reason behind our higher rates of labor dystocia and slower labors, but it'd be really useful to be able to show that conclusively.

If we can document more malpositions in women of size, then we could raise awareness of the possibility among care providers and then use chiropractic care (to prevent malpositions) and manual rotation techniques (to lower the c-section rate associated with OP babies during labor) to improve outcomes.  And perhaps we could keep care providers from just assuming that inefficient uterine contractions and/or soft tissue dystocia is always to blame, as they usually do now.  

Bottom line, if we can elucidate whether or not there are increased rates of malpositions in women of size, we can incorporate the interventions that improve outcome when malpositions are encountered (chiropractic care, maternal repositioning, more patience during labor, manual rotation) and probably lower the cesarean rate in women of size.

Iatrogenic Factors in Cesarean Rates - A couple of recent studies have found that the labors of obese women were managed differently, with far more interventions, more inductions, and a lower threshold for surgical delivery.  When these factors are controlled for, the higher cesarean rate in obese women was either markedly attenuated or it completely disappeared.  I'd love to see more follow-up on these studies in a similar vein.  

The high cesarean rate in women of size is not only about direct iatrogenic factors, but they do likely play a strong role in it.  Until care providers are willing to objectively look at their own role in poorer outcomes, care will not improve markedly in this group.  

Compare Those with Good Outcomes to Those with Poorer Outcomes - Researchers need to start acknowledging that many women of size have good outcomes and start studying these women.  They need to compare women who had good outcomes vs. those who had poorer outcomes and see if they can gain more clues about underlying causes of problems.

For example, if obese women who experience pre-eclampsia have higher hyperinsulinemia rates than obese women who do not experience pre-eclampsia, then perhaps treating women with metformin or fixing insulin receptor/signaling issues will help lower the rates of pre-eclampsia.  Or if obese women who experience a birth defect have lower pre-existing folate stores, then pre-conception blood testing and treating those with low folate stores will help prevent more birth defects in this group. Or if they find that obese women who do not develop GD have consistently higher exercise rates than those who do develop it, then increasing exercise rates is an easy intervention to promote.

The point is that at this point, everyone is so busy blaming and shaming the fat mother for complications that virtually no one is exploring why some fat women have great outcomes and some do not.  Examining the differences between the two groups might help elucidate the real causes of complications in women of size, and might give some really concrete directions for improving outcome.

PCOS and Breastfeeding - There is some preliminary research that shows that PCOS can impact milk supply and lower breastfeeding rates, but we have very little data on how many women with PCOS are affected, and why some with PCOS are affected and others are not.

Research on the impact of PCOS on milk supply has been out for more than 10 years, yet little follow-up research  has been done, and rarely is this confounding factor even mentioned in studies on why breastfeeding rates are lower in women of size. Nor has anyone studied possible interventions (metformin, goat's rue, progesterone supplements, etc.) to see if these could improve milk supply in affected PCOS women.  Considering how important breastfeeding is to a mother and baby's long-term health, it's long past time for far more attention to be paid to this issue.

Health at Every Size® and Pregnancy Outcome - Again, if weight loss before pregnancy is the only tool in our toolkit for improving outcome, we are greatly limiting our choices.  A Health At Every Size approach has been shown to improve outcomes in non-pregnant women; might it improve outcomes in pregnancy too?  

We need to uncouple weight loss from exercise and promotion of healthy habits in the research.  When "lifestyle interventions" are shown to improve outcome, was it really from the minimal weight loss associated with these interventions, or from the increased levels of exercise and improved habits instead?  If we focus on exercise and improved habits, will we improve outcomes without risking the long-term weight gain so commonly associated with weight cycling?  We need research targeted to this question, and we need it now.

Final Thoughts

Thanks for listening, Santa. I will be waiting with bated breath for studies on these topics and a general improvement in the direction of research around obesity and pregnancy.

Researchers and care providers, are you listening too?  Wouldn't you like to be a Santa's Helper and help improve outcomes among women of size?  A more thoughtful and targeted approach to research on obesity and pregnancy would go a long way towards achieving that goal.

Friday Fluff: Yoga Cat Silliness

Here's a cute little Friday Fluff entry for the holidays.

This is a video of a woman doing yoga, and her cat "helping."

I did prenatal yoga and loved it.  I tried to carry it over outside of pregnancy but between the babies and the cats climbing all over me, I could never make it work very well. 

This woman makes it work impressively, even with feline "help."  I'm impressed!

Misleading Wording: Vertical vs. Low Transverse Incisions

Recently, we discussed cesarean incisions in "obese" women, and specifically the pros and cons of a low transverse (side-to-side) incision vs. a vertical (up-down) incision.

As we noted before, for many years doctors were taught that doing an incision under an obese woman's belly fat ("pannus" in medical jargon) made it prone to infection because of the "bacteriologic cesspool" (yes, actual quote) found in the warm, moist conditions in that area.  Many were therefore taught to do a vertical incision in very fat women to lower the risk for wound complications.

However, some studies show a greatly increased risk for wound complications/blood loss with vertical incisions in obese women.  Yet to this day, many still cling to this teaching, despite a lack of support in the medical literature for it.  

Just after my post on the topic was published, a new study on the subject came out.  Here's what the abstract says (my emphasis):

After controlling for confounding factors, no difference in wound complication based on type of skin incision was apparent. The type of skin incision does not appear to be associated with wound complications in the obese parturient; however, larger studies would be needed to confirm this finding.

Sure makes it sound like a vertical incision is just as good as a low transverse one, right?  But look more closely at the full text of the study and the picture begins to change.

What The Study Really Shows

In the study, the number of vertical incisions was n=25, whereas the number of low transverse incisions was much higher, n=213.  The authors note that this was not enough to conclusively decide which incision was better, and that bigger trials were needed.  Very true.

Although the abstract gives lip service to this, the phrasing in the abstract makes it sound like vertical incisions did not result in worse outcomes, but that they needed larger studies to confirm that.  

But the thing is, the study did find worse outcomes with vertical incisions.  5 of the 25 vertical incisions (or 20%) experienced a problem with wound separation, as opposed to 22 out of 213 (or 10%) of the low transverse incisions.

So in the study, vertical incisions had twice the rate of wound separation, but because of the small number of vertical incisions, this difference did not rise to statistical significance.  

The authors were quite forward with this information in their conclusion:

We found that vertical skin incisions are associated with increased odds of postoperative wound separation, although this difference did not reach statistical significance. Although many variables factor into a surgeon’s decision on what type of skin incision to perform, the results of our study do not support the use of vertical skin incisions to reduce wound complications among obese women at the time of cesarean delivery.

That doesn't sound like what the abstract was implying, does it? Too bad the editors of the journal did not see fit to word the abstract more clearly.  They should have acknolwedged that there was no statistical significance, yes, but that there was a strong trend towards worse outcomes with vertical incisions, and that the study was underpowered to detect a statistically significant difference.

They did acknowledge the need for larger studies, but in the context of this abstract's wording it sounded like they needed larger studies to confirm that vertical was just as safe ─ when that's not at all what the authors said in the study.

Final Thoughts

OBs are very busy people and they often do not have time to read the full text of every journal article they run across.  Many just go by the conclusion of the abstracts.  Unfortunately, this abstract gives the mistaken impression that vertical incisions have outcomes just as good as low transverse incisions, when what data we have does not support this.  

A more definitive study is needed, one with a large enough sample to confirm or deny whether vertical incisions are associated with poorer outcomes.  All our research so far suggests that they are, but what we need is access to a really large database that records maternal BMI, types of incision used, and tracks post-op complications thoroughly. Perhaps the MFMU database? Researchers, are you listening?

In the meantime, I suppose it's some comfort that apparently, most women of size who have cesareans are getting low transverse incisions.  YAY.  We need to do less cesareans in women of size, period, but at least most of the cesareans in this group are being done with low transverse incisions.  Small comfort, but I'll take it.

But the stories I hear from women of size suggest that even so, too many obese women are STILL being subjected to the greater risks and ugliness of vertical incisions.  In fact, in this study, 11% of obese women were still being subjected to vertical incisions.  That's too many.  Sometimes, vertical incisions can be needed, but not one out of every ten sections.

Vertical incisions don't "prevent" infection or improve outcome in any way; research suggests it actually increases blood loss, operative time, and wound complications; it increases the likelihood of a classical uterine incision underneath (which is associated with more morbidity short- and long-term); and it creates an ugly scar that negatively impacts a fat woman's sense of self. 

Considering the number of cesareans done every year on women of size, it's time someone accessed a large database and debunked this outdated teaching once and for all.  Until that is done, however, doctors need to acknowledge the clear trend in the research and not use vertical incisions routinely in women of size. 

Am J Perinatol. 2011 Nov 21. Type of Skin Incision and Wound Complications in the Obese Parturient. McLean M, et al. PMID: 22105439

We examined the relationship between type of skin incision at time of cesarean delivery and postoperative wound complications in the obese parturient. Women with a body mass index (BMI) of greater than 29 who had undergone cesarean delivery at The University of North Carolina were identified from the Pregnancy, Infection and Nutrition study. Inpatient and outpatient medical records were reviewed for maternal demographics as well as intrapartum and intraoperative characteristics. The exposure of interest was type of incision, classified as vertical or transverse. The primary outcome was wound complication, defined as partial or complete wound separation. Logistic regression analysis was used to create a final model of risk factors for wound complications while controlling for potentially confounding variables. From 1998 to 2005, 238 women with a BMI greater than 29 who underwent cesarean delivery were identified. Of these 238 women, a vertical skin incision was performed in 25 (11%) and a transverse skin incision in 213 (89%). The overall incidence of wound complications in this group was 13%. BMI was associated with wound complications (p less than 0.01). After controlling for confounding factors, no difference in wound complication based on type of skin incision was apparent. The type of skin incision does not appear to be associated with wound complications in the obese parturient; however, larger studies would be needed to confirm this finding. Increased BMI is associated with a higher rate of wound complications.

Open Thread: What Do You Want To Tell Caregivers?

I'm speaking next week to a group of midwives (and possibly some doctors) about caring for women of size.

I'll be presenting lots of facts and figures and discussing research studies, but I'm also there to represent the voice of consumers, specifically of women of size.

So what in particular do you think is most important for these caregivers to know about caring for women of size?  How do you want to be treated? How do you not want to be treated?

How should caregivers responsibly discuss risk with women of size?  How can they improve outcomes in women of size? What do you most wish you could say to your own caregivers about the care you received during your pregnancies (or if you were to have one)?  About your gynecological care?  What constitutes good care in women of size?

This is an open thread; please feel free to add your comments.  However, remember that caregivers will be reading this thread in the future and we want to promote constructive dialogue about improving care in women of size.  Please keep comments constructive and helpful, even as you make the points you feel need to be made.

I hope this will generate some interesting dialogue and give some thought-provoking feedback to caregivers.

*P.S. Logistical note: For those who asked.....by no means am I done with the PCOS series.  It just went on hiatus for a bit while I worked on some major deadlines on other projects.  It will be a periodic series. Stay tuned!

Cesarean Incision Choice in Women of Size: Up-Down or Side-to-Side

One major problem with the medical care of "obese" patients is that it's often based on what doctors think they know about obesity, rather than being truly evidence-based.

Certain maxims get taught about obesity, it influences medical procedures and protocols, and no one ever questions whether these beliefs are true or whether resulting protocols actually improve outcome. 

Often, no one has even researched the question; they just assume outcomes are improved because everyone "knows" this way is best when dealing with fat patients.

More and more we are finding that these assumptions and protocols do not improve outcome, and in fact, sometimes actually worsen outcome. 

Cesarean incision type in "obese" women is one of these issues. 

Vertical Versus Transverse Incisions: What's Been Taught

Doctors were taught for many years that a vertical (up-and-down) incision was better than a transverse (side-to-side) incision in "morbidly obese" and especially in "super-obese" patients.

They were told that a vertical incision was superior because the area under a fat woman's "apron" or "pannus" (the droopy belly flap overlap that some women have) was hot, moist, and prone to infection.  Therefore, to lower the risk for infection, a vertical incision was made to avoid the area under the pannus. 

I've seen this maxim repeated over and over in the medical literature throughout the years.  And certainly, on my website I have the stories of a number of big moms who were given a vertical cesarean (low vertical or "classical"--i.e. stem to stern) and told it was "necessary" because of their obesity. 

Yet to my surprise, until recently, few studies had actually EXAMINED whether a vertical incision actually improved outcomes or not in "obese" women. 

Certainly it seems intuitive that avoiding the area under the belly might lower the risk for infection.  But interestingly, several studies show the opposite ─ that vertical "up-down" incisions don't improve outcome at all ─ or actually worsen them. And they are certainly far more scarring and unsightly for the women involved.

The Studies That Examine Incisions in Women of Size

Interestingly, there were very few studies on this topic for a very long time; doctors were just taught without question that vertical incisions would reduce the risk of infection and speed up operating time.

Over time, many doctors began using low transverse incisions on women with moderate obesity, and eventually some began expanding their use into women with more "severe" obesity as well.  As a result, many women of size did have low transverse incisions, while other doctors kept using vertical incisions on "supersized" women. Yet few people studied which was superior until about 10 years ago.

In 2001, D'Heureux-Jones et al. presented a paper on a small study that compared different combinations of incisions in obese patients.  They found that the low transverse (skin and uterine) incision was the best incision for obese women because it was faster and had less morbidity associated with it.  Vertical abdominal incisions had the highest blood loss rate.  They concluded that a low transverse incision was advantageous "because it improves speed of operation, blood loss, and rate of complications" in obese patients.

In 2003, Wall et al. did a larger study examining this question. They examined the records of 239 women with a BMI of 35 or more. The wound complication rate was 12.1%, or nearly 1 in 8 women of this size. They found that vertical incisions were associated with twelve times the risk for wound complications.

Alanis 2010 found that vertical incisions had greater blood loss in super-obese women (BMI 50+), and they did not improve outcome. Contrary to expectations, they also found that vertical incisions also had increased operative time.  To improve outcome in this group, they suggested forgoing surgical drains and promoting low transverse incisions.

Bell et al. (2011) studied 424 women with BMI greater than 35 who had a cesarean between 2004 and 2006, including 41 who had a vertical incision.  After adjusting for confounders, the study found that vertical skin incisions were not associated with higher rates of wound complications or blood loss.

However, if the full text of the study is examined, there actually were quite a bit more wound complications (14.6% in the vertical incision group vs. 7.6% in the low transverse group) and blood transfusions (9.8% in the vertical group vs. 1.6% in the low transverse group).  These simply did not rise to statistical significance after controlling for confounders. The adjusted odds ratios were 1.91 for wound complication and 2.78 for blood transfusion with vertical incisions, but the confidence intervals were very wide and crossed 1.0, so the results could not be said to be statistically significant.  However, the trend towards more complications with a vertical skin incision was very clear.  With more subjects in the vertical incision arm, these differences might have risen to statistical significance.

Other Problems with Vertical Incisions

In addition to these concerns, research also indicates that vertical incisions tend to be less strong than transverse incisions, and more prone to dehiscence (coming apart) during recovery.

Women with classical incisions also tend to experience more complications, including post-operative pulmonary issues, more pain, blood transfusions, infections, and more admissions to intensive care units afterwards.

Most importantly, vertical skin incisions often meant vertical incisions in the uterus below. For example, both Bell et al. (2011) and Alanis 2010 found increased rates of vertical/classical incisions in the uterus when vertical skin incisions were used.  Bell found that when doctors used a vertical skin incision on obese women, 66% (two-thirds!) went on to use a classical vertical uterine incision too.

A classical vertical uterine incision places these women at strong risk for future complications, particularly uterine rupture, should any more pregnancies occur.

Bakhshi 2010 found that women with a prior classical cesarean had longer hospitalizations, longer operative times, and more admissions to intensive care units in a subsequent pregnancy.  Most importantly, they had a greatly increased incidence of scar separations in their pregnancies compared to women with a prior low transverse uterine incision (2.46% vs. 0.27%).

As the authors of Alanis 2010 say in their study:

Our results also support the use of Pfannenstiel incisions in obese patients with a large panniculus and contradict classic teaching by veteran surgeons and obstetrical texts. It has been written that transverse abdominal incisions made under the pannicular fold exist in “a warm, moist, anaerobic environment associated with impaired bacteriostasis . . .[that] promotes the proliferation of numerous microorganisms, producing a veritable bacteriologic cesspool.” However, we are unable to locate any evidence to support this popular conclusion...

Transverse abdominal incisions are less painful and allow for earlier mobilization and decreased pulmonary complications. Furthermore, vertical abdominal incisions were associated with vertical hysterotomy in our study, usually a result of inadequate access to the lower uterine segment. When the incision extends into the contractile portion of the uterus, a vertical hysterotomy has a profound impact on future pregnancy. Therefore, it is important to incorporate practices, like transverse abdominal incisions, that facilitate low uterine incisions.

It is notable that the authors could not find any evidence in the research to support the common teaching about use of vertical incisions to prevent infections in obese women.  Again, this shows that many maxims that are taught about obesity and pregnancy are not necessarily supported by evidence.

Although some studies have found that outcomes were statistically similar between vertical incisions and low transverse incisions (usually because of too few partcipants), none have shown better outcome with vertical incisions.

Given the lack of data showing vertical incisions to be superior, not to mention the associated post-operative and future risks with them, the question is why these vertical incisions continue to be used in women of size.

Cosmetic Considerations

Furthermore, it must be pointed out that vertical incisions can be very scarring emotionally and physically.

Long-term Results from Low Transverse Incision in a woman of size
photo from website reader

A low transverse incision is not usually terribly visible long after it's healed. Although all scars are annoying to deal with and can have long-term emotional impact, a transverse incision tends to have less long-term psychological impact because it's further down on the abdomen and not nearly as obviously visible.

Although still traumatic to many women, a transverse scar is less mutilating to a woman's general sense of self.

On the other hand, a vertical incision often leaves a line of separated-looking tissue underneath, as demonstrated in the following pictures.

Recent Vertical Incision on a Woman of Size
From pregnancy.about.com 

Long-Term Results of a Vertical Incision on a Woman of Size
photo from blog reader

Long-Term Results of Vertical Incision
photo from website reader

Some doctors have the attitude that it "doesn't matter" if an incision is vertical in a fat woman. Some have even told fat women that they gave them a vertical incision because "it's not like you're going to be wearing a bikini."

This is an unjust, callous, and unreasonable reason for imposing a vertical incision.  Whether or not they ever wear a bikini is irrelevant to the discussion.  It matters to the woman and her partner.

Botched Vertical CS Incision
from makemeheal.com 

Women with vertical incisions often complain that their incision "looks like a giant butt" on their frontside, and find it unsexy and humiliating for partners to see.  It also can create problems under clothes and limit what fabrics and styles people choose to wear.

Although it's "just" cosmetic, a vertical skin incision can have profound impact on a woman's body esteem.  Unless there is a better outcome associated with it, it simply should not be used routinely in women of size.

Conclusion

Although the practice of doing a vertical or classical incision on "very obese" women has declined somewhat over the years, it is still done at times.  Some doctors do it because they still believe that it's "safer" and less prone to infection in women of size; some do it because it can be technically and physically difficult to do low transverse incisions on women with a larger belly.

While it is important to acknowledge that it is harder to do cesareans on very fat women, and there can be occasions where alternate incisions become necessary, most of the time low transverse incisions are very do-able in fat women, even "morbidly obese" and "super obese" women.

As the authors of Alanis 2010 say in their study:

Our results also support the use of Pfannenstiel incisions in obese patients with a large panniculus and contradict classic teaching by veteran surgeons and obstetrical texts...
Although a Pfannenstiel incision can be challenging in obese patients with an overhanging panniculus, it is usually feasible in all but the most obese women.

Doctors must start questioning the conventional wisdom that they are taught about what's best for "obese" people.  They need to find out if this teaching is actually based on real research, and if so, whether the research has adequately controlled for confounding factors.

Once doctors actually started looking into the question, research showed that it is NOT necessary to do vertical incisions in fat women, even "massively obese" women.  Outcomes are no better or are actually poorer when vertical incisions are used, despite what many doctors have been taught for so long.

The tendency towards greater blood loss, more wound complications, poorer cosmetic outcomes, more classical uterine incisions (and associated negative impact on future pregnancies) all suggest that vertical incisions should be avoided in most obese women.

Low transverse incisions have been used successfully even in extremely obese women (BMI of 88) in case reports found in the medical literature.  Unless there are other complicating factors to consider, a vertical skin incision should NOT be used routinely in fat women.

References

Vertical Incisions vs. Low Transverse Incisions in Women of Size

Obstet Gynecol. 2003 Nov;102(5 Pt 1):952-6. Vertical skin incisions and wound complications in the obese parturient. Wall PD, Deucy EE, Glantz JC, Pressman EK.  PMID: 14672469

OBJECTIVE: To examine the relationship between the type of skin incision and postoperative wound complications in an obese population.
METHODS: A hospital-based perinatal database was used to identify women with a body mass index (BMI) of greater than 35 undergoing their first cesarean delivery. Hospital and outpatient medical records were reviewed for the following variables: age, insurance status, BMI, gestational age at delivery, birth weight, smoking history, prior abdominal surgery, existing comorbidities, preoperative hematocrit, chorioamnionitis, duration of labor and membrane rupture, dilation at time of cesarean delivery, type of skinand uterine incision, estimated blood loss, operative time, antibiotic prophylaxis, use of subcutaneous drains or sutures, endometritis, and length of stay. The primary outcome variable was any wound complication requiring opening the incision. Multiple logistic regression analysis was completed to determine which of these factors contributed to the incidence of wound complications.
RESULTS: From 1994 to 2000, 239 women with a BMI greater than 35 undergoing a primary cesarean delivery were identified. The overall incidence of wound complications in this group of severely obese patients was 12.1%. Factors associated with wound complications included vertical skin incisions (odds ratio [OR] 12.4, P less than .001) and endometritis (OR 3.4, P = .03). A high preoperative hematocrit was protective (OR .87, P = .03). No other factors were found to impact wound complications.
CONCLUSION: Primary cesarean delivery in the severely obese parturient has a high incidence of wound complications. Our data indicate that a vertical skin incision is associated with a higher rate of wound complications than a transverse incision.

D’Heureux-Jones AM. Incision choice for cesarean celivery in obese patients: experience in a university hospital. Obstetrics & Gynecology. 2001 Apr;97(4 Suppl 1):S62-S63. http://www.sciencedirect.com/science/article/pii/S0029784401012959

Objective: Cesarean deliveries in obese patients are surgically difficult and associated with a higher incidence of complications. The choices of skin or uterine incision are subjective. Our aim was to determine the impact of different incisions on the speed of the operation and the intraoperative and postoperative morbidity in obese patients.
Methods: We conducted a 14-month retrospective review of all primary singleton cesarean deliveries performed at our institution. The abdominal (vertical: V, or Pfannenstiel: P) and uterine incision (low transverse: L, or classical: C) were evaluated by one-way and two-way ANOVA for their impact on the time of delivery (skin–baby) based on maternal weight in obese (>200 lb) versus nonobese women. Measures of intraoperative and postoperative morbidity included EBL, wound infections, and metritis.
Results: Seventy-one patients were subjects of this study. Forty-five patients (63%) met criteria for obesity (265.1 ± 8.4 lbs), significantly different from nonobese patients (156.5 ± 4.1 lbs). PL was the most frequent association both in the obese (64%, n = 29) and nonobese (88%, n = 23), with an average skin–baby time of 9.4 ± 0.8 minutes and 9.9 ± 1.1minutes, respectively (P < 0.05). In both obese and nonobese patients, a C was associated with a higher rate of prematurity and NICU admission. When a C was performed, the time was longer if the patient was obese (16.4 ± 2.8 min) versus nonobese (9.07 + 1.2 min), P = 0.03). Skin incisions did not affect the speed of delivery. In obese patients, VL had the highest EBL (1,167 ± 3.57 cc) and PL the lowest (1,075 ± 5.1cc, P = 0.02), both increased compared with nonobese patients with similar incisions. Metritis, but not wound infection, was more frequent in obese patients (20%) versus nonobese patients (3%), irrespective of the incision type. Length of stay was not affected either by obesity or by incision type.
Conclusions: The combination of P and L is preferred for cesarean delivery in both obese and nonobese patients. For obese patients, PL is further advantageous because it improves speed of operation, blood loss, and rate of complications.

Complications of cesarean delivery in the massively obese parturient. Alanis MC, Villers MS, Law TL, Steadman EM, Robinson CJ. Am J Obstet Gynecol. 2010 Sep;203(3):271.31-7.   PMID: 20678746

OBJECTIVE: The objective of the study was to determine predictors of cesarean delivery morbidity associated with massive obesity.
STUDY DESIGN: This was an institutional review board-approved retrospective study of massively obese women (body mass index, greater than/=50 kg/m(2)) undergoing cesarean delivery. Bivariable and multivariable analyses were used to assess the strength of association between wound complication and various predictors.
RESULTS: Fifty-eight of 194 patients (30%) had a wound complication. Most (90%) were wound disruptions, and 86% were diagnosed after hospital discharge (median postoperative day, 8.5; interquartile range, 6-12). Subcutaneous drains and smoking, but not labor or ruptured membranes, were independently associated with wound complication after controlling for various confounders. Vertical abdominal incisions were associated with increased operative time, blood loss, and vertical hysterotomy.
CONCLUSION: Women with a BMI 50 kg/m(2) or greater have a much greater risk for cesarean wound complications than previously reported. Avoidance of subcutaneous drains and increased use of transverse abdominal wall incisions should be considered in massively obese parturients to reduce operative morbidity.

Eur J Obstet Gynecol Reprod Biol. 2011 Jan;154(1):16-9. Epub 2010 Sep 15. Abdominal surgical incisions and perioperative morbidity among morbidly obese women undergoing cesarean delivery. Bell J, Bell S, Vahratian A, Awonuga AO.  PMID: 20832161

OBJECTIVE: To test the hypothesis that there is no difference in perioperative morbidity and the type of uterine incisions between vertical skin incisions (VSI) and low transverse skin incisions (LTSI) at the time of cesarean delivery in morbidly obese women.
STUDY DESIGN: Retrospective cohort study of morbidly obese women (BMI greater than 35 kg/m(2)) who underwent cesarean delivery between June 2004 and December 2006.
RESULTS: During the study, 424 morbidly obese women underwent cesarean section. Patients with VSI were older (31.0 ± 6.2 years vs. 26.7 ± 5.8 years), heavier (48.2 ± 9.1 kg/m(2) vs. 41.7 ± 6.7 kg/m(2)), and more likely to have a classical than a low transverse uterine incision (65.9% vs. 7.3%), p less than 0.001. After controlling for confounders, women with VSI did not have an increase in perioperative morbidity, but underwent more vertical uterine incisions (adjusted odds ratio = 18.49, 95% CI: 6.44, 53.07).
CONCLUSION: VSI and LTSI are safe in morbidly obese patients undergoing cesarean section, but there is a tendency for increased vertical uterine incisions in those who underwent VSI.

Risks of Classical Cesareans 

Obstet Gynecol. 2002 Oct;100(4):633-7. Maternal and perinatal morbidity associated with classic and inverted T cesarean incisions. Patterson LS, O'Connell CM, Baskett TF.  PMID: 12383525

OBJECTIVE: To estimate the maternal and perinatal morbidity associated with cesarean delivery involving the upper uterine segment compared with that of low transverse cesarean delivery. METHODS: A 19-year review of a perinatal database and the relevant charts was used to determine the maternal and perinatal morbidity associated with low transverse cesarean, classic cesarean, and inverted "T" cesarean deliveries. RESULTS:Over the 19 years, 1980-1998, there were 19,726 cesarean deliveries: low transverse cesarean, 19,422 (98.5%); classiccesarean, 221 (1.1%); and inverted T cesarean, 83 (0.4%). As a proportion of all cesarean deliveries, the rates of low transverse cesarean and classic cesarean have remained stable, whereas the rate of inverted T cesarean has risen from 0.2% to 0.9%. Maternal morbidity (puerperal infection, blood transfusion, hysterectomy, intensive care unit admission, death) and perinatal morbidity (stillborn fetus, neonatal death, 5 minute Apgar less than 7, intensive care) were significantly higher in classic cesarean compared to low transverse cesarean. Some maternal morbidity (puerperal infection, blood transfusion) and perinatal morbidity (5 minute Apgar less than 7, intensive care) were also significantly higher for inverted T cesarean compared to low transverse cesarean. CONCLUSION: Classic cesarean section has a higher maternal and perinatal morbidity than inverted T cesarean and much higher than low transverse cesarean. There is no increased maternal or perinatal morbidity if an attempted low transverse incision has to be converted to an inverted "T" incision compared to performing a classic cesarean section.

Am J Perinatol. 2010 Nov;27(10):791-6. Epub 2010 May 10. Maternal and neonatal outcomes of repeat cesarean delivery in women with a prior classical versus low transverse uterine incision. Bakhshi T, et al.  PMID: 20458666

We compared maternal and neonatal outcomes following repeat cesarean delivery (CD) of women with a prior classical CD with those with a prior low transverse CD. The Maternal Fetal Medicine Units Network Cesarean Delivery Registry was used to identify women with one previous CD who underwent an elective repeat CD prior to the onset of labor at ≥36 weeks. Outcomes were compared between women with a previous classical CD and those with a prior low transverse CD. Of the 7936 women who met study criteria, 122 had a prior classical CD. Women with a prior classical CD had a higher rate of classical uterine incision at repeat CD (12.73% versus 0.59%; P less than 0.001), had longer total operative time and hospital stay, and had higher intensive care unit admission. Uterine dehiscence was more frequent in women with a prior classical CD (2.46% versus 0.27%, odds ratio 9.35, 95% confidence interval 1.76 to 31.93). After adjusting for confounding factors, there were no statistical differences in major maternal or neonatal morbidities between groups. Uterine dehiscence was present at repeat CD in 2.46% of women with a prior classical CD. However, major maternal morbidities were similar to those with a prior low transverse CD.