Class III Obese Women's Preferences and Concerns for Cesarean Skin Incision: A Multicenter Survey

Abstract

Objective This study aims to assess class III obese women's preferences and concerns regarding cesarean delivery (CD) skin incisions.

Study Design Through the National Perinatal Research Consortium (NPRC), women with body mass index ≥ 40 kg/m² at the time of enrollment completed an anonymous survey in English or Spanish. We evaluated seven domains of preferences and concerns about the cesarean skin incision.

Results We surveyed 546 women at five NPRC sites. Median age (interquartile range) was 29 (25, 35) years; 364 (66%) were parous and 161 (30%) had a prior CD. Women self-identified race/ethnicity as White (31%), non-Hispanic Black (31%), Hispanic (31%), other (6%), and not reported (1%). A total of 542 women (99%) rated both delivering the baby in the best possible condition and decreasing incision opening/infection risk as important. Women were less likely to rate other domains as important (all p < 0.001), including: having least pain possible, n = 521 (95%); decreasing the risk of complications in the next pregnancy, n = 490 (90%); decreasing interference with breastfeeding, n = 474 (87%); decreasing operative time, n = 388 (71%); and having the least visible incision, n = 369 (68%).

Conclusion Women with class III obesity prioritize immediate maternal and fetal safety regarding CD skin incision over other concerns including cosmetic outcome.

Keywords

obesity - cesarean delivery - patient preference - survey

• References

• 1 Flegal KM, Carroll MD, Kit BK, Ogden CL. Prevalence of obesity and trends in the distribution of body mass index among US adults, 1999-2010. JAMA 2012; 307 (5) 491-497
• 2 Ogden CL, Carroll MD, Curtin LR, McDowell MA, Tabak CJ, Flegal KM. Prevalence of overweight and obesity in the United States, 1999-2004. JAMA 2006; 295 (13) 1549-1555
• 3 Wang Y, Beydoun MA, Liang L, Caballero B, Kumanyika SK. Will all Americans become overweight or obese? estimating the progression and cost of the US obesity epidemic. Obesity (Silver Spring) 2008; 16 (10) 2323-2330
• 4 Stotland NE, Hopkins LM, Caughey AB. Gestational weight gain, macrosomia, and risk of cesarean birth in nondiabetic nulliparas. Obstet Gynecol 2004; 104 (4) 671-677
• 5 Crane JM, Murphy P, Burrage L, Hutchens D. Maternal and perinatal outcomes of extreme obesity in pregnancy. J Obstet Gynaecol Can 2013; 35 (7) 606-611
• 6 Chu SY, Kim SY, Schmid CH , et al. Maternal obesity and risk of cesarean delivery: a meta-analysis. Obes Rev 2007; 8 (5) 385-394
• 7 Kominiarek MA, Vanveldhuisen P, Hibbard J , et al; Consortium on Safe Labor. The maternal body mass index: a strong association with delivery route. Am J Obstet Gynecol 2010; 203 (3) 264.e1-264.e7
• 8 Kominiarek MA, Zhang J, Vanveldhuisen P, Troendle J, Beaver J, Hibbard JU. Contemporary labor patterns: the impact of maternal body mass index. Am J Obstet Gynecol 2011; 205 (3) 244.e1-244.e8
• 9 Brocato BE, Thorpe Jr EM, Gomez LM, Wan JY, Mari G. The effect of cesarean delivery skin incision approach in morbidly obese women on the rate of classical hysterotomy. J Pregnancy 2013; 2013: 890296 DOI: 10.1155/2013/890296.
• 10 Smid MC, Kearney MS, Stamilio DM. Extreme obesity and postcesarean wound complications in the maternal-fetal medicine unit cesarean registry. Am J Perinatol 2015; 32 (14) 1336-1341
• 11 Stamilio DM, Scifres CM. Extreme obesity and postcesarean maternal complications. Obstet Gynecol 2014; 124 (2 Pt 1): 227-232
• 12 Robinson HE, O'Connell CM, Joseph KS, McLeod NL. Maternal outcomes in pregnancies complicated by obesity. Obstet Gynecol 2005; 106 (6) 1357-1364
• 13 Edwards RK, Cantu J, Cliver S, Biggio Jr JR, Owen J, Tita AT. The association of maternal obesity with fetal pH and base deficit at cesarean delivery. Obstet Gynecol 2013; 122 (2 Pt 1): 262-267
• 14 Alanis MC, Goodnight WH, Hill EG, Robinson CJ, Villers MS, Johnson DD. Maternal super-obesity (body mass index > or = 50) and adverse pregnancy outcomes. Acta Obstet Gynecol Scand 2010; 89 (7) 924-930
• 15 Marrs CC, Moussa HN, Sibai BM, Blackwell SC. The relationship between primary cesarean delivery skin incision type and wound complications in women with morbid obesity. Am J Obstet Gynecol 2014; 210 (4) 319.e1-319.e4
• 16 Montori VM, Brito JP, Murad MH. The optimal practice of evidence-based medicine: incorporating patient preferences in practice guidelines. JAMA 2013; 310 (23) 2503-2504
• 17 van der Weijden T, Pieterse AH, Koelewijn-van Loon MS , et al. How can clinical practice guidelines be adapted to facilitate shared decision making? A qualitative key-informant study. BMJ Qual Saf 2013; 22 (10) 855-863
• 18 Wall PD, Deucy EE, Glantz JC, Pressman EK. Vertical skin incisions and wound complications in the obese parturient. Obstet Gynecol 2003; 102 (5 Pt 1): 952-956
• 19 Alanis MC, Villers MS, Law TL, Steadman EM, Robinson CJ. Complications of cesarean delivery in the massively obese parturient. Am J Obstet Gynecol 2010; 203 (3) 271.e1-271.e7
• 20 Thornburg LL, Linder MA, Durie DE, Walker B, Pressman EK, Glantz JC. Risk factors for wound complications in morbidly obese women undergoing primary cesarean delivery. J Matern Fetal Neonatal Med 2012; 25 (9) 1544-1548
• 21 McLean M, Hines R, Polinkovsky M, Stuebe A, Thorp J, Strauss R. Type of skin incision and wound complications in the obese parturient. Am J Perinatol 2012; 29 (4) 301-306
• 22 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 (1) 16-19
• 23 Vermillion ST, Lamoutte C, Soper DE, Verdeja A. Wound infection after cesarean: effect of subcutaneous tissue thickness. Obstet Gynecol 2000; 95 (6 Pt 1): 923-926
• 24 Barry MJ, Edgman-Levitan S. Shared decision making—pinnacle of patient-centered care. N Engl J Med 2012; 366 (9) 780-781
• 25 Joosten EA, DeFuentes-Merillas L, de Weert GH, Sensky T, van der Staak CP, de Jong CA. Systematic review of the effects of shared decision-making on patient satisfaction, treatment adherence and health status. Psychother Psychosom 2008; 77 (4) 219-226
• 26 Nyman VM, Prebensen ÅK, Flensner GE. Obese women's experiences of encounters with midwives and physicians during pregnancy and childbirth. Midwifery 2010; 26 (4) 424-429
• 27 Furber CM, McGowan L. A qualitative study of the experiences of women who are obese and pregnant in the UK. Midwifery 2011; 27 (4) 437-444
• 28 Smith D, Lavender T. The maternity experience for women with a body mass index ≥ 30 kg/m2: a meta-synthesis. BJOG 2011; 118 (7) 779-789
• 29 Porter M, van Teijlingen E, Chi Ying Yip L, Bhattacharya S. Satisfaction with cesarean section: qualitative analysis of open-ended questions in a large postal survey. Birth 2007; 34 (2) 148-154
• 30 Erb L, Hill G, Houston D. A survey of parents' attitudes toward their cesarean births in Manitoba hospitals. Birth 1983; 10 (2) 85-92
• 31 Green JM, Baston HA. Feeling in control during labor: concepts, correlates, and consequences. Birth 2003; 30 (4) 235-247
• 32 Somera MJ, Feeley N, Ciofani L. Women's experience of an emergency caesarean birth. J Clin Nurs 2010; 19 (19–20) 2824-2831
• 33 Smid MC, Smiley SG, Schulkin J , et al. The problem of the pannus: physician preference survey and a review of the literature on cesarean skin incision in morbidly obese women. Am J Perinatol 2016; 33 (5) 463-472