Smarter Decisions,
Better Care

UpToDate synthesizes the most recent medical information into evidence-based practical recommendations clinicians trust to make the right point of care decisions.

  • Rigorous editorial process: Evidence-based treatment recommendations
  • World-Renowned physician authors: over 5,100 physician authors around the globe
  • Innovative technology: integrates into the workflow; access from EMRs

For more information, click below.


Subscribers log in here


Cesarean delivery of the obese woman

INTRODUCTION

Cesarean delivery is a frequent occurrence among pregnant obese women and requires careful perioperative planning to ensure optimal maternal and newborn outcomes [1,2]. The risks and challenges of the procedure increase as the severity of obesity increases.

The following body mass index (BMI) classifications for obesity were adopted by the National Institute of Health (NIH) and World Health Organization (WHO) and have been endorsed by most expert groups [3,4]. For whites, Hispanics, and blacks:

  • Class I obesity — BMI of 30.0 to 34.9 kg/m2
  • Class II obesity — BMI of 35.0 to 39.9 kg/m2
  • Class III obesity — BMI ≥40 kg/m2 (also called severe, morbid, or extreme obesity)

Although the WHO identified additional trigger points for intervention and public health policy for Asians, obesity continues to be defined as a BMI >30 kg/m2 in this population [5].

Issues specifically relating to cesarean delivery in 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 anesthesia and surgery issues in obese individuals are reviewed separately:

                        

Subscribers log in here

To continue reading this article you must have access through your hospital or your group practice, log in to your personal subscription, or purchase a personal subscription. For more information, click below.
Literature review current through: Apr 2013. | This topic last updated: Feb 28, 2013.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2013 UpToDate, Inc.
References
Top
  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. World Health Organization. Obesity: preventing and managing the global epidemic. Report of a WHO convention, Geneva, 1999. WHO technical report series 894, Geneva 2000.
  4. Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults--The Evidence Report. National Institutes of Health. Obes Res 1998; 6 Suppl 2:51S.
  5. WHO Expert Consultation. Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies. Lancet 2004; 363:157.
  6. 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.
  7. Perlow JH, Morgan MA. Massive maternal obesity and perioperative cesarean morbidity. Am J Obstet Gynecol 1994; 170:560.
  8. 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.
  9. Myles TD, Gooch J, Santolaya J. Obesity as an independent risk factor for infectious morbidity in patients who undergo cesarean delivery. Obstet Gynecol 2002; 100:959.
  10. Hood DD, Dewan DM. Anesthetic and obstetric outcome in morbidly obese parturients. Anesthesiology 1993; 79:1210.
  11. Alexander CI, Liston WA. Operating on the obese woman--A review. BJOG 2006; 113:1167.
  12. Gunatilake RP, Perlow JH. Obesity and pregnancy: clinical management of the obese gravida. Am J Obstet Gynecol 2011; 204:106.
  13. 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.
  14. Wolfe HM, Gross TL, Sokol RJ, et al. Determinants of morbidity in obese women delivered by cesarean. Obstet Gynecol 1988; 71:691.
  15. 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.
  16. Shenkman Z, Shir Y, Brodsky JB. Perioperative management of the obese patient. Br J Anaesth 1993; 70:349.
  17. Martens MG, Kolrud BL, Faro S, et al. Development of wound infection or separation after cesarean delivery. Prospective evaluation of 2,431 cases. J Reprod Med 1995; 40:171.
  18. DeMaria EJ, Carmody BJ. Perioperative management of special populations: obesity. Surg Clin North Am 2005; 85:1283.
  19. Loubert C, Fernando R. Cesarean delivery in the obese parturient: anesthetic considerations. Womens Health (Lond Engl) 2011; 7:163.
  20. 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.
  21. Cullen A, Ferguson A. Perioperative management of the severely obese patient: a selective pathophysiological review. Can J Anaesth 2012; 59:974.
  22. Wong CY, O'Moore-Sullivan T, Leano R, et al. Alterations of left ventricular myocardial characteristics associated with obesity. Circulation 2004; 110:3081.
  23. Dronge AS, Perkal MF, Kancir S, et al. Long-term glycemic control and postoperative infectious complications. Arch Surg 2006; 141:375.
  24. 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.
  25. 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.
  26. Antimicrobial prophylaxis for surgery. Treat Guidel Med Lett 2012; 10:73.
  27. 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.
  28. Bratzler DW, Dellinger EP, Olsen KM, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm 2013; 70:195.
  29. 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.
  30. 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.
  31. Roofthooft E. Anesthesia for the morbidly obese parturient. Curr Opin Anaesthesiol 2009; 22:341.
  32. Sajid MS, Shakir AJ, Khatri K, Baig MK. The role of perioperative warming in surgery: a systematic review. Sao Paulo Med J 2009; 127:231.
  33. Kumar S, Wong PF, Melling AC, Leaper DJ. Effects of perioperative hypothermia and warming in surgical practice. Int Wound J 2005; 2:193.
  34. Hamilton CL, Riley ET, Cohen SE. Changes in the position of epidural catheters associated with patient movement. Anesthesiology 1997; 86:778.
  35. McClelland SH, Bogod DG, Hardman JG. Pre-oxygenation and apnoea in pregnancy: changes during labour and with obstetric morbidity in a computational simulation. Anaesthesia 2009; 64:371.
  36. Dixon BJ, Dixon JB, Carden JR, et al. Preoxygenation is more effective in the 25 degrees head-up position than in the supine position in severely obese patients: a randomized controlled study. Anesthesiology 2005; 102:1110.
  37. Altermatt FR, Muñoz HR, Delfino AE, Cortínez LI. Pre-oxygenation in the obese patient: effects of position on tolerance to apnoea. Br J Anaesth 2005; 95:706.
  38. Collins JS, Lemmens HJ, Brodsky JB, et al. Laryngoscopy and morbid obesity: a comparison of the "sniff" and "ramped" positions. Obes Surg 2004; 14:1171.
  39. Aziz MF, Kim D, Mako J, et al. A retrospective study of the performance of video laryngoscopy in an obstetric unit. Anesth Analg 2012; 115:904.
  40. Jones SJ, Kinsella SM, Donald FA. Comparison of measured and estimated angles of table tilt at Caesarean section. Br J Anaesth 2003; 90:86.
  41. 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.
  42. Wall PD, Deucy EE, Glantz JC, Pressman EK. Vertical skin incisions and wound complications in the obese parturient. Obstet Gynecol 2003; 102:952.
  43. 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.
  44. 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.
  45. 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.
  46. 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.
  47. 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.
  48. Ahern JK, Goodlin RC. Cesarean section in the massively obese. Obstet Gynecol 1978; 51:509.
  49. 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.
  50. 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.
  51. Morrow CP, Hernandez WL, Townsend DE, Disaia PJ. Pelvic celiotomy in the obese patient. Am J Obstet Gynecol 1977; 127:335.
  52. Gross TL. Operative considerations in the obese pregnant patient. Clin Perinatol 1983; 10:411.
  53. 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.
  54. 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.
  55. McNeil PM, Sugerman HJ. Continuous absorbable vs interrupted nonabsorbable fascial closure. A prospective, randomized comparison. Arch Surg 1986; 121:821.
  56. Israelsson LA, Jonsson T. Closure of midline laparotomy incisions with polydioxanone and nylon: the importance of suture technique. Br J Surg 1994; 81:1606.
  57. Anderson ER, Gates S. Techniques and materials for closure of the abdominal wall in caesarean section. Cochrane Database Syst Rev 2004; :CD004663.
  58. 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.
  59. Gates S, Anderson ER. Wound drainage for caesarean section. Cochrane Database Syst Rev 2005; :CD004549.
  60. 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.
  61. 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.
  62. 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.
  63. 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.
  64. Mackeen AD, Berghella V, Larsen ML. Techniques and materials for skin closure in caesarean section. Cochrane Database Syst Rev 2012; 9:CD003577.
  65. Nuthalapaty FS, Kuper SG, Higdon HL 3rd. Staples compared with subcuticular suture for skin closure after cesarean delivery: a systematic review and meta-analysis. Obstet Gynecol 2011; 118:166.
  66. 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.
  67. 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.
  68. 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.
  69. 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.
  70. Stannard JP, Gabriel A, Lehner B. Use of negative pressure wound therapy over clean, closed surgical incisions. Int Wound J 2012; 9 Suppl 1:32.
  71. Sarsam SE, Elliott JP, Lam GK. Management of wound complications from cesarean delivery. Obstet Gynecol Surv 2005; 60:462.
  72. 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.
  73. 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.
  74. 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.
  75. 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.