Journal of Obesity & Weight Loss Therapy
Open Access

Super obesity, defined as a Body Mass Index (BMI) ≥ 50 kg/m², presents significant challenges in obstetric care [1]. The prevalence of super obesity among reproductive-age women has doubled in the past decade, mirroring the overall obesity epidemic [2]. This trend has led to an increase in high-risk pregnancies and cesarean deliveries in this population.

Performing cesarean deliveries in super obese patients is associated with unique challenges, including increased operative time, higher blood loss and a higher risk of wound complications [3]. The choice of skin incision plays a key role in navigating these challenges and can significantly impact postoperative outcomes.

Types of skin incisions

Three main types of skin incisions are commonly used for cesarean deliveries in super obese patients:

Low transverse (Pfannenstiel) incision: This traditional approach involves a slightly curved incision placed 2–3 cm above the pubic symphysis [4]. It offers excellent cosmetic results and is associated with less postoperative pain. However, in super obese patients, the overhanging pannus can obstruct access to this area. Retraction of the pannus is essential, using tape or other commercially available products.

High transverse incision (suprapannus): Placed above the pannus, this incision can be either infraumbilical or supraumbilical [5]. It provides better exposure of the lower uterine segment in patients with a large pannus but may be associated with increased wound complications.

Vertical incision: A midline incision from above or around the umbilicus up to the pubic symphysis [6]. This approach offers rapid abdominal entry and can be extended if needed, but it is associated with poorer cosmetic outcomes, higher rates of "classical or vertical” uterine incision (for supraumbilical vertical incisions) and a higher risk of wound dehiscence.

The choice between these incisions depends on various factors, including the size and position of the pannus, urgency of the procedure and surgeon preference [7].

Comparative outcomes of different incision types
Recent studies have shed light on the outcomes associated with different incision types in super obese patients:

Wound complications: Baranco et al., found that high transverse incisions were associated with significantly higher rates of wound infection compared to low transverse incisions (13.8% vs. 4.9%) [8]. This finding is consistent with other studies that have reported increased wound morbidity with high transverse incisions [9].

Operative time: The same study reported longer skin incision to delivery times for high transverse incisions compared to low transverse incisions (14.98 min vs. 11.09 min) [8]. However, total operative time was not significantly different after adjusting for confounding factors.

Blood loss: While some studies suggest increased blood loss with vertical incisions, others have found no significant difference between incision types when controlling for patient characteristics [8, 10].

Postoperative pain and recovery: Patient-reported outcomes regarding postoperative pain have been mixed, with some studies suggesting less pain with low transverse incisions [11]. Most studies have not addressed pain, so evidence is limited.

Long-term outcomes: Limited data exist on long-term outcomes such as incisional hernia formation. Some studies suggest a higher risk of hernia formation with vertical incisions, but data specific to super obese patients are lacking [12].

Factors influencing incision choice

Several factors influence the choice of skin incision in super obese patients:

Body habitus and pannus size/position: The size and position of the pannus are critical factors. A large, pendulous pannus may necessitate a high transverse or vertical incision to achieve adequate exposure [13].

Urgency of cesarean delivery: In emergency situations, the need for rapid abdominal entry may favor a vertical incision [14].

Prior surgical history: Previous incisions may influence the current choice, with some surgeons preferring to use the same incision type to avoid crossing scars [15].

Anticipated fetal position/presentation: Certain fetal positions may require more extensive exposure, potentially influencing incision choice [16].

Surgeon experience and preference: Variation in practice patterns exists, with some surgeons more comfortable with certain incision types [17].

Perioperative Considerations

Preoperative planning and patient positioning: Proper positioning is important. Techniques such as pannus retraction or elevation can improve surgical field visibility [18].

Anesthesia challenges: Super obesity complicates both regional and general anesthesia. Difficulties with spinal placement and potential airway management issues must be anticipated [19].

Antibiotic prophylaxis: Weight-based dosing of antibiotics is essential. For super obese patients undergoing cesarean delivery, the recommended dose of cefazolin is 3 grams administered within 60 mins before skin incision [20]. This dose should be repeated if the surgery is prolonged (>3 h) or if there is significant blood loss (>1,500 ml) [21].

In addition to cefazolin, a single dose of azithromycin (500 mg intravenously) is recommended for all women undergoing cesarean delivery during labor or after membrane rupture [22]. This adjunctive therapy has been shown to significantly reduce the rate of postoperative infections, including endometritis and wound infections, in both non-obese and obese populations [23].

Venous thromboembolism prophylaxis: Super obese patients are at high risk for VTE. Early mobilization, mechanical prophylaxis and weight-based pharmacological prophylaxis are recommended [24].

Use of plastic self-retaining surgical retractors

The Alexis O Wound Protector-Retractor and the Mobius® Retractor are self-retaining, disposable wound retractors that have gained popularity in cesarean deliveries, particularly for patients with obesity [25]. Benefits include improved surgical field visualization, potential reduction in wound infection rates, easier fetal extraction and protection of wound edges [26].

A randomized controlled trial by Hardy-Fairbanks et al., compared two types of retractors at cesarean delivery and found that the Alexis retractor reduced operative time and improved surgeon satisfaction [27]. While the Alexis retractor shows promise, high-quality evidence specifically for super obese populations is limited. A randomized controlled trial by Hinkson et al., in obese women (BMI ≥ 30 kg/m²) found no significant difference in surgical site infections between those who had the Alexis retractor and those who did not, although the study was not powered to detect differences in the super obese subgroup [28].

Challenges in delivering the fetus

Delivering the fetus during cesarean section in super obese patients can be particularly challenging due to several factors:

Limited visualization: The thick abdominal wall and large pannus can obscure the surgical field, making it difficult to visualize the lower uterine segment and fetal parts [29–31].

Increased distance to the uterus: The distance from the skin incision to the uterus is often increased, making manual extraction more difficult [32].

Reduced maneuverability: The confined space within the surgical field can limit the obstetrician's ability to maneuver and apply necessary pressure for delivery [33].

Increased risk of fetal macrosomia: Super obese women are at higher risk of having macrosomic infants, which can further complicate delivery [34].

To address these challenges, several techniques can be used:

Vacuum-assisted fetal extraction: In cases where manual extraction is difficult, vacuum-assisted delivery can be considered. This technique involves applying a soft vacuum cup to the fetal head to aid in extraction. However, it should be used judiciously and with caution to avoid fetal injury [35].

Breech extraction of a cephalic fetus: The fetus can be delivered feet-first in cases of high floating fetal head or failed attempts at cephalic delivery by performing internal podalic version or, with low fetal station, by reverse breech extraction [36].

Fundal pressure: Carefully applied fundal pressure by an assistant can help guide the fetus towards the incision. However, excessive force should be avoided to prevent uterine rupture or other complications [37].

Extended uterine incision: In some cases, extending the uterine incision (e.g. J or T incision) may be necessary to facilitate delivery. This decision should be made carefully, considering the implications for future pregnancies [38].

These techniques should be used judiciously and tailored to each individual case, balancing the need for successful delivery with the potential risks involved.

Postoperative wound suction devices

Negative Pressure Wound Therapy (NPWT) is a potential tool for reducing wound complications in high-risk surgical patients [39]. Meta-analyses have suggested a decrease in wound infections but have been limited by heterogeneity [40, 41]. Recent large randomized controlled trials have not demonstrated improvement in wound outcomes [42].

Routine NPWT does not seem justified based on current evidence, and any use should be individualized, acknowledging that no studies are likely to focus on patients with the highest BMI and other comorbid risk factors.

Wound care and postoperative management

Closure techniques: A meta-analysis by Mackeen et al., found that suture closure was associated with a lower risk of wound complications compared to staples in obese patients undergoing cesarean delivery [43]. This finding was based on a subset of the included trials that had stratified results by BMI. More recent randomized trials in patients with morbid obesity have not shown any benefit to suture compared with staple closure and this was reaffirmed by a subsequent meta-analysis [44–47].

Postoperative monitoring: Frequent wound checks are essential for early detection of complications. Some institutions have implemented standardized protocols for wound monitoring in high-risk patients [48].

Patient education: Clear instructions on wound care, hygiene and the importance of early mobilization are essential. Patients should be educated on signs of wound complications and when to seek medical attention [49].

Future directions

While large prospective randomized trials are typically considered the gold standard for guiding surgical decisions, such studies may be particularly challenging to conduct in the context of cesarean delivery techniques for super obese patients. This difficulty is exemplified by the experience of Marrs et al., who conducted a randomized trial comparing Pfannenstiel versus vertical skin incisions in women with a BMI ≥ 40 kg/m² [15].

Given these difficulties, future research efforts may need to consider alternative approaches such as large-scale observational studies, quality improvement initiatives, novel study designs, focus on specific subgroups and patient-centered outcomes research (Table 1).

Table 1: Comparison of skin incision types.

The choice of skin incision for cesarean delivery in super obese patients remains a challenging clinical decision. While current evidence suggests that low transverse incisions may be associated with fewer wound complications when feasible, the decision must be individualized based on patient characteristics, surgical urgency and operator experience. 

The existing evidence should be interpreted with caution. BMI is a practical inclusion criterion for research, but it does not consistently reflect the body habitus of an individual patient. Studies have also used a variety of definitions and BMI cutoffs, so it is difficult to determine which evidence is most applicable in each case. 

As the prevalence of super obesity continues to rise, obstetricians must be prepared to manage these complex cases. In the absence of clear evidence from large, randomized trials, clinicians should rely on a combination of the best available evidence, clinical experience and careful consideration of individual patient factors. A multidisciplinary approach, meticulous preoperative planning and vigilant postoperative care remain essential to optimizing outcomes in this high-risk population. 

Ongoing research, quality improvement initiatives and innovative study designs are essential to enhancing our understanding and improving care for super obese women undergoing cesarean delivery. While the path to definitive evidence may be challenging, continued efforts to refine our approach to these complex cases are vital for improving maternal and neonatal outcomes.

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