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Cesarean delivery of the obese woman

Richard P Porreco, MD
Section Editors
Charles J Lockwood, MD, MHCM
David L Hepner, MD
Deputy Editor
Vanessa A Barss, MD, FACOG


Obesity is a risk factor for cesarean delivery, and the risks and challenges of cesarean delivery increase with increasing severity of obesity (table 1). Perioperative planning helps to reduce these risks and ensure optimal maternal and newborn outcomes.

Issues relating to cesarean delivery of the obese woman will be discussed here. General issues relating to cesarean delivery, the numerous maternal and perinatal risks of obesity during pregnancy and the immediate postpartum period, and anesthetic and surgical issues in obese individuals are reviewed separately:

(See "Cesarean delivery: Preoperative planning and patient preparation".)

(See "Cesarean delivery: Surgical technique".)

(See "Cesarean delivery: Postoperative issues".)

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Literature review current through: Oct 2017. | This topic last updated: Nov 07, 2017.
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  1. Poobalan AS, Aucott LS, Gurung T, et al. Obesity as an independent risk factor for elective and emergency caesarean delivery in nulliparous women--systematic review and meta-analysis of cohort studies. Obes Rev 2009; 10:28.
  2. Marshall NE, Guild C, Cheng YW, et al. Maternal superobesity and perinatal outcomes. Am J Obstet Gynecol 2012; 206:417.e1.
  3. Weiss JL, Malone FD, Emig D, et al. Obesity, obstetric complications and cesarean delivery rate--a population-based screening study. Am J Obstet Gynecol 2004; 190:1091.
  4. Sebire NJ, Jolly M, Harris JP, et al. Maternal obesity and pregnancy outcome: a study of 287,213 pregnancies in London. Int J Obes Relat Metab Disord 2001; 25:1175.
  5. Alexander CI, Liston WA. Operating on the obese woman--A review. BJOG 2006; 113:1167.
  6. Gunatilake RP, Perlow JH. Obesity and pregnancy: clinical management of the obese gravida. Am J Obstet Gynecol 2011; 204:106.
  7. Porreco RP, Adelberg AM, Lindsay LG, Holdt DG. Cesarean birth in the morbidly obese woman: a report of 3 cases. J Reprod Med 2007; 52:231.
  8. Wolfe HM, Gross TL, Sokol RJ, et al. Determinants of morbidity in obese women delivered by cesarean. Obstet Gynecol 1988; 71:691.
  9. Usha Kiran TS, Hemmadi S, Bethel J, Evans J. Outcome of pregnancy in a woman with an increased body mass index. BJOG 2005; 112:768.
  10. Vricella LK, Louis JM, Mercer BM, Bolden N. Anesthesia complications during scheduled cesarean delivery for morbidly obese women. Am J Obstet Gynecol 2010; 203:276.e1.
  11. Tonidandel A, Booth J, D'Angelo R, et al. Anesthetic and obstetric outcomes in morbidly obese parturients: a 20-year follow-up retrospective cohort study. Int J Obstet Anesth 2014; 23:357.
  12. Loubert C, Fernando R. Cesarean delivery in the obese parturient: anesthetic considerations. Womens Health (Lond) 2011; 7:163.
  13. Poirier P, Alpert MA, Fleisher LA, et al. Cardiovascular evaluation and management of severely obese patients undergoing surgery: a science advisory from the American Heart Association. Circulation 2009; 120:86.
  14. Cullen A, Ferguson A. Perioperative management of the severely obese patient: a selective pathophysiological review. Can J Anaesth 2012; 59:974.
  15. Wong CY, O'Moore-Sullivan T, Leano R, et al. Alterations of left ventricular myocardial characteristics associated with obesity. Circulation 2004; 110:3081.
  16. Dronge AS, Perkal MF, Kancir S, et al. Long-term glycemic control and postoperative infectious complications. Arch Surg 2006; 141:375.
  17. Pevzner L, Swank M, Krepel C, et al. Effects of maternal obesity on tissue concentrations of prophylactic cefazolin during cesarean delivery. Obstet Gynecol 2011; 117:877.
  18. Swank ML, Wing DA, Nicolau DP, McNulty JA. Increased 3-gram cefazolin dosing for cesarean delivery prophylaxis in obese women. Am J Obstet Gynecol 2015; 213:415.e1.
  19. Chopra T, Zhao JJ, Alangaden G, et al. Preventing surgical site infections after bariatric surgery: value of perioperative antibiotic regimens. Expert Rev Pharmacoecon Outcomes Res 2010; 10:317.
  20. Bratzler DW, Dellinger EP, Olsen KM, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm 2013; 70:195.
  21. Bratzler DW, Houck PM, Surgical Infection Prevention Guideline Writers Workgroup. Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgical Infection Prevention Project. Am J Surg 2005; 189:395.
  22. Valent AM, DeArmond C, Houston JM, et al. Effect of Post-Cesarean Delivery Oral Cephalexin and Metronidazole on Surgical Site Infection Among Obese Women: A Randomized Clinical Trial. JAMA 2017; 318:1026.
  23. Calfee DP, Grünebaum A. Postoperative Antimicrobial Prophylaxis Following Cesarean Delivery in Obese Women: An Exception to the Rule? JAMA 2017; 318:1012.
  24. Soens MA, Birnbach DJ, Ranasinghe JS, van Zundert A. Obstetric anesthesia for the obese and morbidly obese patient: an ounce of prevention is worth more than a pound of treatment. Acta Anaesthesiol Scand 2008; 52:6.
  25. Roofthooft E. Anesthesia for the morbidly obese parturient. Curr Opin Anaesthesiol 2009; 22:341.
  26. Chakravartty S, Sarma DR, Patel AG. Rhabdomyolysis in bariatric surgery: a systematic review. Obes Surg 2013; 23:1333.
  27. Cluver C, Novikova N, Hofmeyr GJ, Hall DR. Maternal position during caesarean section for preventing maternal and neonatal complications. Cochrane Database Syst Rev 2010; :CD007623.
  28. Graatsma EM, Miller J, Mulder EJ, et al. Maternal body mass index does not affect performance of fetal electrocardiography. Am J Perinatol 2010; 27:573.
  29. Wall PD, Deucy EE, Glantz JC, Pressman EK. Vertical skin incisions and wound complications in the obese parturient. Obstet Gynecol 2003; 102:952.
  30. Alanis MC, Villers MS, Law TL, et al. Complications of cesarean delivery in the massively obese parturient. Am J Obstet Gynecol 2010; 203:271.e1.
  31. Thornburg LL, Linder MA, Durie DE, et al. Risk factors for wound complications in morbidly obese women undergoing primary cesarean delivery. J Matern Fetal Neonatal Med 2012; 25:1544.
  32. McLean M, Hines R, Polinkovsky M, et al. Type of skin incision and wound complications in the obese parturient. Am J Perinatol 2012; 29:301.
  33. Bell J, Bell S, Vahratian A, Awonuga AO. Abdominal surgical incisions and perioperative morbidity among morbidly obese women undergoing cesarean delivery. Eur J Obstet Gynecol Reprod Biol 2011; 154:16.
  34. Tixier H, Thouvenot S, Coulange L, et al. Cesarean section in morbidly obese women: supra or subumbilical transverse incision? Acta Obstet Gynecol Scand 2009; 88:1049.
  35. Ahern JK, Goodlin RC. Cesarean section in the massively obese. Obstet Gynecol 1978; 51:509.
  36. Viegas CM, Viegas OA. Preventing a surgical complication during cesarean delivery in a morbidly obese patient: a simple apparatus to retract the abdominal panniculus. MedGenMed 2006; 8:52.
  37. Houston MC, Raynor BD. Postoperative morbidity in the morbidly obese parturient woman: supraumbilical and low transverse abdominal approaches. Am J Obstet Gynecol 2000; 182:1033.
  38. Morrow CP, Hernandez WL, Townsend DE, Disaia PJ. Pelvic celiotomy in the obese patient. Am J Obstet Gynecol 1977; 127:335.
  39. Gross TL. Operative considerations in the obese pregnant patient. Clin Perinatol 1983; 10:411.
  40. Derzie AJ, Silvestri F, Liriano E, Benotti P. Wound closure technique and acute wound complications in gastric surgery for morbid obesity: a prospective randomized trial. J Am Coll Surg 2000; 191:238.
  41. Orr JW Jr, Orr PF, Barrett JM, et al. Continuous or interrupted fascial closure: a prospective evaluation of No. 1 Maxon suture in 402 gynecologic procedures. Am J Obstet Gynecol 1990; 163:1485.
  42. McNeil PM, Sugerman HJ. Continuous absorbable vs interrupted nonabsorbable fascial closure. A prospective, randomized comparison. Arch Surg 1986; 121:821.
  43. Israelsson LA, Jonsson T. Closure of midline laparotomy incisions with polydioxanone and nylon: the importance of suture technique. Br J Surg 1994; 81:1606.
  44. Anderson ER, Gates S. Techniques and materials for closure of the abdominal wall in caesarean section. Cochrane Database Syst Rev 2004; :CD004663.
  45. Chelmow D, Rodriguez EJ, Sabatini MM. Suture closure of subcutaneous fat and wound disruption after cesarean delivery: a meta-analysis. Obstet Gynecol 2004; 103:974.
  46. Hellums EK, Lin MG, Ramsey PS. Prophylactic subcutaneous drainage for prevention of wound complications after cesarean delivery--a metaanalysis. Am J Obstet Gynecol 2007; 197:229.
  47. Gates S, Anderson ER. Wound drainage for caesarean section. Cochrane Database Syst Rev 2013; :CD004549.
  48. Allaire AD, Fisch J, McMahon MJ. Subcutaneous drain vs. suture in obese women undergoing cesarean delivery. A prospective, randomized trial. J Reprod Med 2000; 45:327.
  49. Magann EF, Chauhan SP, Rodts-Palenik S, et al. Subcutaneous stitch closure versus subcutaneous drain to prevent wound disruption after cesarean delivery: a randomized clinical trial. Am J Obstet Gynecol 2002; 186:1119.
  50. Ramsey PS, White AM, Guinn DA, et al. Subcutaneous tissue reapproximation, alone or in combination with drain, in obese women undergoing cesarean delivery. Obstet Gynecol 2005; 105:967.
  51. Ibrahim MI, Moustafa GF, Al-Hamid AS, Hussein MR. Superficial incisional surgical site infection rate after cesarean section in obese women: a randomized controlled trial of subcuticular versus interrupted skin suturing. Arch Gynecol Obstet 2014; 289:981.
  52. Fyfe EM, Thompson JM, Anderson NH, et al. Maternal obesity and postpartum haemorrhage after vaginal and caesarean delivery among nulliparous women at term: a retrospective cohort study. BMC Pregnancy Childbirth 2012; 12:112.
  53. Larsen TB, Sørensen HT, Gislum M, Johnsen SP. Maternal smoking, obesity, and risk of venous thromboembolism during pregnancy and the puerperium: a population-based nested case-control study. Thromb Res 2007; 120:505.
  54. O'Connor DJ, Scher LA, Gargiulo NJ 3rd, et al. Incidence and characteristics of venous thromboembolic disease during pregnancy and the postnatal period: a contemporary series. Ann Vasc Surg 2011; 25:9.
  55. Jarzyna D, Jungquist CR, Pasero C, et al. American Society for Pain Management Nursing guidelines on monitoring for opioid-induced sedation and respiratory depression. Pain Manag Nurs 2011; 12:118.
  56. Smid MC, Dotters-Katz SK, Grace M, et al. Prophylactic Negative Pressure Wound Therapy for Obese Women After Cesarean Delivery: A Systematic Review and Meta-analysis. Obstet Gynecol 2017; 130:969.
  57. McDaid C, Maund E, Rice S, et al. Paracetamol and selective and non-selective non-steroidal anti-inflammatory drugs (NSAIDs) for the reduction of morphine-related side effects after major surgery: a systematic review. Health Technol Assess 2010; 14:1.
  58. American Society of Anesthesiologists Task Force on Obstetric Anesthesia. Practice guidelines for obstetric anesthesia: an updated report by the American Society of Anesthesiologists Task Force on Obstetric Anesthesia. Anesthesiology 2007; 106:843.
  59. Abouleish E, Rawal N, Rashad MN. The addition of 0.2 mg subarachnoid morphine to hyperbaric bupivacaine for cesarean delivery: a prospective study of 856 cases. Reg Anesth 1991; 16:137.
  60. Levin A, Klein SL, Brolin RE, Pitchford DE. Patient-controlled analgesia for morbidly obese patients: an effective modality if used correctly. Anesthesiology 1992; 76:857.
  61. Stamilio DM, Scifres CM. Extreme obesity and postcesarean maternal complications. Obstet Gynecol 2014; 124:227.