Cesarean Birth: Overview of Issues For Patients With Obesity - UpToDate

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Cesarean birth: Overview of issues for patients with

obesity
Authors: Richard P Porreco, MD, Jean-Ju Sheen, MD
Section Editors: David L Hepner, MD, William Grobman, MD
Deputy Editor: Vanessa A Barss, MD, FACOG
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Mar 2023. | This topic last updated: Jul 06, 2022.
INTRODUCTION
Obesity is a risk factor for cesarean birth, and the risks and challenges of cesarean birth
increase with increasing severity of obesity. Perioperative planning and appropriate
intervention help to reduce these risks and ensure optimal maternal and newborn
outcomes.
The Enhanced Recovery After Surgery (ERAS) Society has published guidelines for
perioperative care of patients undergoing cesarean birth, the ERAS Cesarean Delivery
Guidelines, which cover the time from decision to operate (starting with the 30 to 60
minutes before skin incision) to hospital discharge [1-3]. The American College of
Obstetricians and Gynecologists (ACOG) has published a guideline for enhanced recovery
after surgery [4]. Other organizations and many hospitals have also created such
guidelines/pathways [5]. However, no specific guideline exists for perioperative care of
patients with obesity undergoing cesarean birth.
This topic will present an overview of issues relating to cesarean birth of the patient with
obesity. Many of these issues are the same as those for the overall obstetric population
and are discussed in detail separately:
● (See "Cesarean birth: Preoperative planning and patient preparation".)
https://www.uptodate.com/contents/cesarean-birth-overview-of-issues-for-patients-with-obesity/print Página 1 de 36
● (See "Cesarean birth: Surgical technique".)

● (See "Cesarean birth: Postoperative care, complications, and long-term sequelae".)
● (See "Anesthesia for cesarean delivery".)
The numerous maternal and perinatal risks of obesity during pregnancy and the
immediate postpartum period and the anesthetic and surgical issues in individuals with
obesity are also reviewed separately:
● (See "Obesity in pregnancy: Complications and maternal management".)

● (See "Anesthesia for the patient with obesity".)
FACTORS TO CONSIDER DURING SURGICAL PLANNING
The following factors should be considered in patients with obesity undergoing cesarean
birth. The relative contribution of each factor to the risk of an adverse outcome, such as
wound infection/disruption, endometritis, or thromboembolism, compared with patients
without obesity has not been clearly defined [6-14].
● Baseline health hazards – Obesity is associated with numerous health hazards

( table 1). (See "Overweight and obesity in adults: Health consequences".)
● Perioperative respiratory dysfunction – Obstructive sleep apnea (OSA) and obesity

hypoventilation syndrome (OHS) are the most important respiratory problems
associated with obesity (see "Obstructive sleep apnea in pregnancy"). However,
patients with obesity without these disorders are still at risk of perioperative
respiratory dysfunction due to functional and mechanical changes related to obesity.
(See "Preanesthesia medical evaluation of the patient with obesity" and "Anesthesia
for the patient with obesity".)
● Type of cesarean birth – Obesity increases the chances of both scheduled and
emergency cesarean birth. Emergency cesareans are associated with higher risks for
intraoperative and postoperative complications than scheduled procedures [15,16].
(See "Obesity in pregnancy: Complications and maternal management", section on
'Cesarean birth'.)
● Need for specialized equipment – Surgery in patients with obesity often requires
specialized equipment (eg, high-weight-capacity operating tables, bariatric width
extenders, lifts, long instruments, large blood pressure cuffs, large pneumatic
compression devices). (See "Hospital accreditation, accommodations, and staffing for
care of the bariatric surgical patient", section on 'Facilities/equipment/instruments'.)
● Difficulty placing intravenous lines – Peripheral intravenous (IV) lines may be

difficult to place due to subcutaneous adiposity. Central venous access may be
needed if peripheral access is tenuous, but central venous access may also be
difficult. Ultrasound guidance can be used for placing central and peripheral venous
catheters. (See "Principles of ultrasound-guided venous access".)
● Difficulty placing neuraxial anesthesia – Placement of neuraxial needles and

catheters can be challenging because the usual anatomic landmarks are not easily
palpable, the patient may be unable to flex their back adequately, and the distance
from skin to target is longer than in patients without obesity. Ultrasound guidance
may be helpful. Although the rate of successful neuraxial anesthesia is similar for
pregnant patients with severe obesity and those without obesity, it is more likely that
placement will require additional attempts and need for repeated placement due to
epidural failure [17,18]. (See "Anesthesia for the patient with obesity", section on
'Neuraxial anesthesia'.)
● Difficulty with ventilation – It is more likely that mask ventilation may be difficult
and intubation may be difficult or may fail. (See "Anesthesia for the patient with
obesity", section on 'Difficulty with airway management'.)
● Longer operative time – Incision-to-delivery time and total operative time are
longer on average.
● Increased blood loss – Mean blood loss is increased, but blood transfusion is not
clearly more frequent.
● Altered pharmacodynamics – Pharmacodynamics may be altered because patients

with obesity have a larger blood volume and volume of distribution for lipophilic
drugs, and a decrease in lean body mass and tissue water, compared with controls
without obesity. These changes predispose patients with obesity to both
subtherapeutic and toxic responses to medications. (See "Anesthesia for the patient
with obesity", section on 'Dosing anesthetic drugs'.)
PREOPERATIVE EVALUATION AND TESTING
● Anesthesia consultation – Ideally, patients with class II or III obesity are scheduled
for an antepartum consultation with the anesthesia team, given the multiple
anesthetic and surgical risk factors discussed above. (See 'Factors to consider during
surgical planning' above.)
Scheduling the consultation in the early to mid-third trimester is prudent in case of

late preterm or early term birth. Preoperative history, physical examination, and
selective testing can identify patients with comorbidities, such as a potentially
difficult airway or obstructive sleep apnea (OSA), that increase their risk of
complications during and following surgery. Preanesthetic evaluation and other
issues related to anesthesia and postoperative care of patients with obesity are
discussed in detail separately. (See "Preanesthesia medical evaluation of the patient
with obesity".)
● Blood bank – A type and screen is generally considered adequate for patients with
obesity and no other high-risk factors for postpartum hemorrhage. The Joint
Commission recommends that hospitals use an evidence-based assessment tool for
determining the risk of hemorrhage in all obstetric patients upon admission to the
labor and delivery and postpartum units, and counsel/manage patients based on
their level of risk [19]. The decision to type and screen versus crossmatch is based on
the clinician's assessment of level of risk. Several tools have been created for risk
assessment, but none are predictive of severe hemorrhage, particularly in the
absence of an obvious high-risk factor (eg, placenta accreta spectrum, placenta
previa, low-lying placenta, placental abruption, coagulopathy, severe anemia) or at
least two moderate risk factors (eg, prior cesarean birth/uterine surgery, multiple
gestation, large fibroids, prior postpartum hemorrhage) [20,21]. Risk assessment
and planning is reviewed separately. (See "Overview of postpartum hemorrhage",
section on 'PPH risk assessment tools and risk-based preparation'.)
● Electrocardiogram – The decision to obtain an ECG should be individualized, taking

into account the following factors. The American Heart Association (AHA) 2009
scientific advisory on cardiovascular evaluation and management of patients with
body mass index (BMI) ≥40 kg/m2 undergoing surgery states that a 12-lead ECG is
reasonable in those with at least one risk factor for perioperative cardiovascular
morbidity (coronary heart disease, congestive heart failure, cerebrovascular disease,

insulin-dependent diabetes mellitus, chronic renal insufficiency with creatinine level
>2.0 mg/dL) or poor exercise tolerance [22]. However, cardiac changes (ventricular
hypertrophy, systolic and/or diastolic dysfunction, atrial fibrillation) can occur in the
absence of these risk factors in patients with longstanding severe obesity, so these
factors should be considered as well [23,24]. (See "Preoperative medical evaluation
of the healthy adult patient", section on 'Electrocardiogram' and "Obesity in adults:
Prevalence, screening, and evaluation", section on 'Assessing obesity-related health
risk' and "Obesity in pregnancy: Complications and maternal management", section
on 'Baseline assessments and referrals'.)
● Perioperative respiratory function – Preoperative identification of OSA helps in

planning interventions to reduce respiratory morbidity, which can be aggravated by
immobility, positioning, pain, and use of opioids. Clinical questionnaires or
prediction scores (eg, STOP-Bang, Berlin) can be used for screening but are less
reliably predictive in pregnant people. Patients with obesity who report snoring,
witnessed apnea, or drowsiness episodes should be referred for evaluation by a
sleep medicine specialist and possible polysomnography. Screening, evaluation, and
treatment of OSA in pregnancy are reviewed in detail separately. (See "Obstructive
sleep apnea in pregnancy".)
PREOPERATIVE INTERVENTIONS TO REDUCE THE RISK OF

COMPLICATIONS
In a large retrospective study of patients undergoing primary and repeat cesarean births,
the rate of intraoperative complications was low (3 to 4 percent of cases) and not
significantly increased in patients with obesity, suggesting that surgical preparedness and
appropriate conduct of surgery can decrease complication rates [16]. These measures are
discussed in the following subsections and below. (See 'Operative procedure' below.)
Prevention of aspiration — Both pregnancy and elevated BMI are consistently associated

with higher rates of gastroesophageal reflux. Measures to reduce the risk of aspiration
(eg, fasting before scheduled cases and avoidance of solid food in labor; administration of
nonparticulate antacids, H2-receptor antagonists and/or metoclopramide) are similar to
those in pregnant patients without obesity. (See "Anesthesia for cesarean delivery",
section on 'Preparation for anesthesia'.)
Prevention of venous thromboembolism — We suggest application of an intermittent

pneumatic compression device sized to accommodate large legs preoperatively, and the
addition of pharmacologic thromboprophylaxis postpartum once the patient is deemed
stable from a surgical/anesthesia standpoint.
Thromboprophylaxis is typically recommended for patients with obesity undergoing

cesarean birth, given that pregnancy, cesarean birth, and obesity are all risk factors for
postpartum venous thromboembolism (VTE). Virtually all pregnant people undergoing
cesarean birth in the United States receive mechanical prophylaxis. Although details
among medical society guidelines vary, both mechanical and pharmacologic
thromboprophylaxis are recommended for patients at higher risk of VTE, such as those
with obesity. Choice of drug (unfractionated versus low molecular weight heparin), timing
of administration, dosing, and duration of thromboprophylaxis (during hospitalization
only versus for six weeks) are reviewed separately. (See "Cesarean birth: Preoperative
planning and patient preparation", section on 'Thromboembolism prophylaxis'.)
Prevention of surgical-site infection — Important components of infection prophylaxis

include using aseptic practices, minimizing duration of surgery, weight-based antibiotic
prophylaxis, and preoperative optimum glycemic management in patients with diabetes
[25]. Selected specific measures in patients with obesity undergoing cesarean birth are
discussed below. (See 'Preparation of the abdomen and vagina' below and 'Antibiotic
prophylaxis' below.)
A general discussion of standard measures to prevent surgical site infections (SSIs) can be
found separately. (See "Antimicrobial prophylaxis for prevention of surgical site infection
in adults" and "Overview of control measures for prevention of surgical site infection in
adults".)
Preparation of the abdomen and vagina — Both the abdomen and vagina are prepped
with an antiseptic solution, as in patients without obesity. The choice and efficacy of
agents for skin and vaginal preparation are reviewed separately. (See "Cesarean birth:
Preoperative planning and patient preparation", section on 'Skin preparation' and
"Cesarean birth: Preoperative planning and patient preparation", section on 'Vaginal
preparation'.)
Antibiotic prophylaxis
● Patients without penicillin allergy – For patients with obesity undergoing cesarean
birth at average risk of infection, dosing is based on weight as follows [26]:
• ≥120 kg: cefazolin 3 g intravenously (IV) within the 60 minutes prior to surgical
incision
• <120 kg: cefazolin 2 g IV within the 60 minutes prior to surgical incision
For patients in labor and/or with rupture of membranes: add azithromycin 500 mg IV
[27].
For patients with ruptured membranes who undergo cesarean birth without
preoperative IV azithromycin, administering cefazolin 2 or 3 g IV preoperatively
followed by cephalexin 500 mg orally plus metronidazole 500 mg orally every 8 hours
for 48 hours following cesarean birth is another approach to reducing SSI [28].
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IBW can be estimated by the calculator (calculator 1) and following formula: IBW, in
kg (females) = 45.5 + (2.3 x inches above 60 inches). (See "Dosing and administration
of parenteral aminoglycosides", section on 'Dosing weight'.)
Evidence — The value of preincision antibiotic prophylaxis for cesarean birth has

been consistently demonstrated in meta-analyses of randomized trials (see "Cesarean
birth: Preoperative planning and patient preparation", section on 'Antibiotic prophylaxis').
However, evidence for optimum dosing in the population of patients with obesity is
limited.
● Higher dosing – Standard doses of antimicrobial agents, particularly the

cephalosporins [30,31], result in low serum and tissue levels in patients with obesity
(≥20 percent of patients with obesity did not achieve minimal inhibitory
concentrations for Gram-negative rods in incisional adipose samples with a 2 g dose
in one study [30]); therefore, higher doses of the prophylactic antimicrobial agent
should be administered [32].
In 2013, guidelines developed jointly by the American Society of Health-System

Pharmacists (ASHP), the Infectious Diseases Society of America (IDSA), the Surgical
Infection Society (SIS), and the Society for Healthcare Epidemiology of America
(SHEA) recommended cefazolin 3 g for patients ≥120 kg undergoing cesarean birth
and 2 g for patients <120 kg [26,29]. They also suggest consideration of additional
intraoperative doses in patients with excessive blood loss or extended surgery
(duration exceeding two half-lives of the drug), which is the standard of care in other
surgeries. (See "Antimicrobial prophylaxis for prevention of surgical site infection in
adults".)
By comparison, the American College of Obstetricians and Gynecologists (ACOG)

recommends a single dose of a first-generation cephalosporin, but dosing is
different (cefazolin 1 g IV for patients <80 kg, 2 to 3 g IV for patients ≥80 kg) [33].
● Extended-spectrum dosing – Emerging data support use of extended-spectrum

antibiotic combinations for patients at high risk of postcesarean infection (eg,
cesareans performed intrapartum or after rupture of membranes). In a randomized
trial of over 1000 patients undergoing unplanned cesarean after receiving cefazolin
with versus without IV azithromycin prophylaxis, the adjunctive azithromycin group
had a significant reduction in the primary composite outcome of endometritis,
wound infection, or other infections (relative risk [RR] 0.51, 95% CI 0.38-0.68), with no
significant difference in the neonatal composite outcome, including death and
serious complications [34]. A meta-analysis of this trial and others that included both
scheduled and unplanned cesareans reported a similar reduction in infection (SSI:
6.3 versus 13.6 percent; RR 0.46, 95% CI 0.34-0.63) [27]. (See "Cesarean birth:
Preoperative planning and patient preparation", section on 'Regimen'.)
● Postpartum antibiotics – Traditionally, prophylaxis has not been continued

postpartum because studies in general surgical populations showed no benefit from
postoperative antimicrobial prophylaxis [29]. However, a randomized trial in over 400
patients with obesity (BMI ≥30 kg/m2) that compared oral cephalexin 500 mg plus
metronidazole 500 mg versus placebo every 8 hours for 48 hours following cesarean
birth (in addition to 2 g IV preoperative cefazolin prophylaxis) reported a reduction in
SSIs (6.4 versus 15.4 percent, RR 0.41, 95% CI 0.22-0.77; number needed to treat to
prevent one SSI: 12) [28].
Post hoc analysis showed that, when comparing the same regimen with placebo, the
126 patients with membrane rupture prior to cesarean had a significant reduction in
SSI (mean difference 20.6 percent, 95% CI 6.9-34.3 percent) that was not
demonstrated in the 277 patients without membrane rupture (difference 3.7
percent, 95% CI -2.3 to 9.6 percent). The frequency of SSI in the control group was
quite high and the dose of IV cefazolin was lower than our recommendation for 3 g
in patients ≥120 kg, thus the results may not be generalizable to hospitals/patients
with obesity with lower SSI rates and patients with obesity who receive a higher dose
of IV cefazolin. It is also unclear if the benefits of postoperative oral antibiotics would
exceed that of administration of IV azithromycin at the time of the cesarean birth.
However, in patients with obesity and ruptured membranes not receiving
preoperative IV azithromycin, this postoperative oral regimen may be considered
[35].
ANESTHESIA
Challenges and complications related to anesthesia are more common in patients with
obesity, and include difficulty with monitoring, positioning, airway management, and
neuraxial techniques, as well as longer surgical duration and increased risk of aspiration
of gastric contents [17].
The choice between general and regional anesthesia should be guided by the urgency of
the case, requirements of the surgical procedure, and comorbidities. Although patient
preferences are also important, regional anesthesia is recommended for this patient
population, especially those with severe obesity, because it is safer than general
anesthesia [36,37]. For patients planning vaginal birth, early placement of a neuraxial
catheter during labor may obviate the need for general anesthesia in case of emergency
cesarean birth.
Anesthesia issues of patients with obesity are reviewed in detail separately:
● (See "Anesthesia for the patient with obesity".)

● (See "Anesthesia for cesarean delivery".)
● (See "Airway management for the pregnant patient".)
OPERATIVE PROCEDURE
Logistics
● Preoperative fetal heart rate monitoring – Fetal heart rate (FHR) monitoring
before the start of surgery can usually be achieved with a traditional Doppler FHR
monitor.
● Choice of operating table – Special operating tables may be needed. For example, a
standard operating table has a weight capacity up to 500 pounds (227 kg), while a
bariatric surgical table has a weight capacity up to 1000 pounds (454 kg). Bariatric
table width extenders can be useful in increasing the support surface of the
operating table. (See "Hospital accreditation, accommodations, and staffing for care
of the bariatric surgical patient", section on 'Operating rooms'.)
● Transferring the patient to the operating table – Moving and positioning the
patient with obesity can be difficult and must be done carefully to prevent falls and
other uncontrolled movements, as well as injury to the patient and staff. A hydraulic
or ceiling lift or an air transfer system (eg, HoverMatt) can be useful to lift and move
the patient, and helps to prevent patient and staff injury. (See "Hospital
accreditation, accommodations, and staffing for care of the bariatric surgical
patient", section on 'Patient lifts'.)
● Patient positioning – Patient positioning is important to limit unfavorable

physiological sequelae (eg, supine hypotension, respiratory dysfunction), provide
optimum exposure for surgical procedures, and reduce the risk of perioperative
nerve, joint, and soft tissue injury. Pressure points (including buttocks, lumbar
region, and shoulders) should be well-padded to prevent skeletal muscle necrosis
[38].
Patients should be positioned with left uterine displacement to minimize the chance
of aortocaval compression and supine hypotension. Traditionally, 15 degrees of
lateral displacement is recommended. (See "Anesthesia for cesarean delivery",
section on 'Intraoperative positioning'.)
● Blood pressure monitoring – Blood pressure must be monitored with an

appropriately sized blood pressure cuff. A thigh cuff is advised if the arm
circumference is 45 to 52 cm and a large adult cuff if arm circumference is 35 to 44
cm (see "Blood pressure measurement in the diagnosis and management of
hypertension in adults", section on 'Cuff size'). If external measurements are not

reliable, which sometimes happens in these cases, blood pressure can be monitored
invasively.
● Intermittent pneumatic compression devices – Intermittent pneumatic

compression devices sized to accommodate large legs are applied preoperatively.
(See "Prevention of venous thromboembolic disease in adult nonorthopedic surgical
patients", section on 'Intermittent pneumatic compression and venous foot pump'.)
● Surgical exposure – A removable adhesive panniculus retractor/retention system or

surgical tape placed prior to start of the cesarean for rostral retraction may improve
exposure without concern for pressure points that may be caused by manual
retraction (as described in a case report of pressure necrosis of the panniculus from
prolonged digital retraction [39]). A self-retaining intraabdominal retractor can be
added for the intraabdominal procedures. In our experience, self-retaining retractors
have not impeded fetal delivery, but this is a theoretic concern.
The panniculus retractor/retention system may be left in place postoperatively to

assist in keeping the incision clean and dry. The clinician should be familiar with the
manufacturer's instructions for duration of use for the device/system as these can
vary.
Of note, retracting an extremely large panniculus onto the thorax has been
associated with cardiopulmonary compromise (eg, hypotension, hypoxia).
● Instruments and other supplies – Long instruments and wide deep retractors
(including panniculus retractors) are usually required to access structures deep in
the pelvis. Appropriately sized gowns and stretchers and monitoring equipment
must be available for patients with obesity. (See "Hospital accreditation,
accommodations, and staffing for care of the bariatric surgical patient", section on
'Operating rooms' and "Hospital accreditation, accommodations, and staffing for
care of the bariatric surgical patient", section on 'Other supplies' and "Hospital
accreditation, accommodations, and staffing for care of the bariatric surgical
patient", section on 'Monitoring and safety devices'.)
Abdominal wall incision — The patient's body habitus, including weight distribution and
panniculus size, need to be carefully assessed before deciding upon the appropriate
incision. The type of incision may affect exposure, ease of fetal extraction, postoperative
pain and respiratory effort, wound strength, and wound complication rates.
● Landmarks – The surgeon must be aware of how abdominal wall adipose tissue can
affect typical anatomic landmarks. The pubic symphysis and iliac crests are reliable
landmarks regardless of maternal body habitus [40]. In contrast, the location of soft
tissue landmarks may be atypical. In patients with an apron-like panniculus, the
umbilicus is a poor landmark for identifying the underlying location of pelvic organs
because it is displaced caudally from its normal location at approximately the level of
the iliac crest. As a result, the umbilicus may be caudal to the lower uterine segment,
and care must be taken to not make an incision that may go through to the other
side of the pannus instead of into the abdominal cavity.
● Transverse or vertical? – The choice of incision should be based on the surgeon's

judgment regarding patient specific technical factors (eg, type of pannus/where the
weight is concentrated). Whether a transverse or vertical incision is superior for the
pregnant patient with obesity remains controversial, as no randomized trials have
shown a clear benefit to one versus the other in these patients [41]. Some
retrospective studies have reported higher wound complication rates in patients
with vertical incisions than in those who underwent a transverse incision (wound
infection: vertical incision 35 to 46 percent; transverse incision 9 to 21 percent) [42-
44]. However, differences in risk factors for wound complications between patients
undergoing one incision versus the other may have accounted for these findings.
Others have not observed a difference in outcome by type of incision after
controlling for confounders [13,45-47].
• Suprapubic low-transverse incision – The adipose tissue two finger-breadths

cephalad to the pubic symphysis is not particularly thick, even in patients with
severe obesity. For patients who weigh less than approximately 400 pounds (181
kg), elevating the panniculus and retracting it cephalad with a panniculus
retractor/retention system or tape as discussed above (see 'Logistics' above)
allows placement of a low-transverse (eg, Pfannenstiel) or low-midline (vertical)
incision [48]. This weight threshold is based on personal experience and other
anecdotal evidence.
A disadvantage of making an incision under the panniculus is that the wound
must heal in a warm, moist environment with higher bacterial colonization, thus
potentially increasing the risk of infection.
• Supraumbilical incision
- Transverse – For patients who weigh over 400 pounds (181 kg), and
particularly those over 600 pounds (272 kg), a transverse supraumbilical
incision has some advantages: it has the strength of the transverse repair,
avoids burying the wound under a large panniculus, and provides excellent
abdominal exposure [12]. Permanent contraception (including
salpingectomy), if desired, is easily achieved with this incision. However, it has
not been proven to be less morbid than a Pfannenstiel incision [42,49] and
the weight threshold is based on personal experience and other anecdotal
evidence.
- Vertical – A vertical supraumbilical incision is another option, when the

panniculus is displaced caudally [50]. With caudal displacement, the
umbilicus cannot be used as a landmark for estimating the location of pelvic
organs; the pubic symphysis and iliac crests must be used.
A disadvantage of supraumbilical incisions is that exposure to the lower uterine

segment can be suboptimal, necessitating a vertical hysterotomy, which is made
in the midportion of the uterus extending toward the fundus. Rarely, this may
require extracting a vertex-presenting fetus as a breech. An alternative
suprapannicular subumbilical incision technique that displaces the panniculus
caudad has been described in a pilot series of 17 patients; the authors state that
it preserves access to the lower uterine segment and a potential low-transverse
hysterotomy [51]. Further investigation is required.
● Incision length – The term fetus is likely to be large so a longer incision than used in
patients without obesity is especially important to facilitate delivery. The alternative
of manually stretching the incision to facilitate fetal extraction would be difficult due
to the thick abdominal wall.
● Technique – The risk of infection can be reduced by not making multiple shallow
strokes by scalpel or electrosurgery (which increases tissue damage) and by avoiding
excessive dissection of the subcutaneous tissues (which increases dead space).
Hysterotomy incision — We prefer a transverse incision in the lower uterine segment

because it is associated with the lowest rate of uterine rupture in subsequent
pregnancies. This is especially important for pregnant patients with obesity in whom rapid
administration of anesthesia and cesarean birth may not be technically possible if the
uterus ruptures in a future pregnancy. The risk of rupture in future pregnancy with a true
low-vertical incision also appears to be low, but vertical incisions often extend into a
portion of the thick upper uterus. Factors involved in choosing the type of hysterotomy
are reviewed in more detail separately. (See "Cesarean birth: Surgical technique", section
on 'Choice of incision' and "Uterine rupture: After previous cesarean birth".)
Fetal extraction — The fetus can be difficult to extract because of the location of the
hysterotomy and/or the surgeon's or assistant's inability to provide adequate fundal
pressure. Some options to facilitate extraction include extraction as a breech or use of one
or two forceps blades or a vacuum device. (See "Cesarean birth: Management of the
deeply impacted head and the floating head".)
Fascial closure
● Midline incision – Mass closure of vertical incisions ( figure 1) may reduce the risk
of dehiscence and hernia formation compared with layered closure. A meta-analysis
of randomized trials of patients undergoing laparotomy for a variety of indications
demonstrated no clear benefit of mass closure, but interpretation was limited by
multiple sources of bias and very heterogeneous patient populations (type and
reason for of surgery, type of incision [eg, transverse, midline]) [52].
The classic Smead-Jones technique (far-far-near-near) or an alternative approach

(far-near-near-far) are acceptable methods ( figure 1) [53]. The key point is to
approximate the fascia without strangulation. Continuous mass closure with
nonabsorbable or slowly absorbable suture has proven safe and equally effective as
interrupted techniques in randomized trials [54-56]. 0-polypropylene nonabsorbable
suture or a delayed absorbable suture, such as looped 0-PDS or 1-PDS, is acceptable.
The continuous suture incorporates a small amount of subcutaneous fat, the rectus
muscle, the rectus sheaths, the transversalis fascia, and, optionally, the peritoneum.
The total length of the suture should be approximately four times the length of the
incision; a suture that is too short increases the risk of hernia formation [57].
Inverted knots keep knot stacks out of the subcutaneous tissues. (See "Principles of
abdominal wall closure".)
● Transverse incision – Few randomized trials have evaluated the optimum closure
technique for transverse fascial incisions. A continuous nonlocking closure with
slowly absorbable #0 or 1 braided suture (eg, polyglactin 910) is a common
approach, but a monofilament (eg, polydioxanone) can also be used [52,58]. (See
"Cesarean birth: Surgical technique", section on 'Fascia'.)
Subcutaneous closure — The subcutaneous adipose layer should be closed when the

layer is ≥2 cm thick; an absorbable 3-0 running suture is commonly used [59,60]. In a
meta-analysis of randomized trials, suture closure of the subcutaneous adipose layer at
cesarean birth decreased the risk of subsequent wound disruption by one-third in
patients with subcutaneous tissue depth ≥2 cm (relative risk [RR] 0.66, 95% CI 0.48-0.91),
but not in those <2 cm (RR 1.01, 95% CI 0.46-2.20) [60].
Drains — Subcutaneous drains are not recommended, as randomized trials show no clear

benefit in the overall obstetric population (wound complications RR 0.85, 95% CI 0.55-1.32;
wound infections RR 1.02, 95% CI 0.85-1.21) [61] or in patients with obesity who have a
subcutaneous closure [43,62,63] or in the general surgical population [64]. In an
observational study of patients with ≥4 cm of subcutaneous thickness at cesarean, the use
of a drain was associated with an increased risk of wound complications [65].
Skin closure — The authors have used subcuticular polypropylene (RPP) and absorbable
sutures, both for infrapannicular and supraumbilical incisions. In three randomized trials
evaluating skin closure techniques in patients with obesity, composite wound
complication rates were generally similar for staple and subcuticular suture methods [66-
68], similar to findings in the overall obstetric population. (See "Cesarean birth: Surgical
technique", section on 'Skin closure'.)
POSTOPERATIVE MORBIDITY
Postpartum morbidities that are more common in patients with obesity after cesarean
birth include wound dehiscence and infection [9], postpartum hemorrhage [69],
thromboembolism [70,71], and pulmonary morbidity (particularly in patients with
obstructive sleep apnea [OSA] or obesity hypoventilation syndrome [OHS]) [72]. These
risks are discussed in detail separately. (See "Obesity in pregnancy: Complications and
maternal management", section on 'Postpartum'.)
POSTOPERATIVE CARE
General measures
● Close monitoring – Patients with obesity require close postoperative monitoring

until recovery of respiratory function. For those with a history of cardiac arrhythmias
or coronary artery disease and/or chronic obstructive pulmonary disease (COPD),
sleep apnea, and/or asthma, admission to a unit that can provide continuous
cardiopulmonary monitoring for as long as it is needed, generally 24 hours, is
advised. In addition to routine assessment of vital signs, use of continuous pulse
oximetry and capnography (where available) can detect impaired oxygenation and
ventilation, respectively. Fluid intake and output should be monitored closely to
maintain euvolemia, especially in patients with cardiopulmonary disease. (See
"Hospital accreditation, accommodations, and staffing for care of the bariatric
surgical patient", section on 'Monitoring and safety devices'.)
All patients should undergo regular assessment of their level of sedation and
respiratory function during wakefulness and sleep. Guidance for monitoring for
respiratory depression after cesarean birth is described separately. (See "Post-
cesarean delivery analgesia", section on 'Side effects and complications'.)
Respiratory depression (eg, respiratory rate <8 to 10 breaths per minute, hypoxemia
[oxygen saturation ≤95 percent], hypercapnia), sedation, poor respiratory effort or
quality, snoring/noisy respiration, or desaturation are indications to rouse the
patient immediately and instruct them to take deep breaths [73]. More invasive
monitoring (eg, pulse oximetry and capnography) may then be required.
● Positioning – Both a head-up, 30-degree position and lateral decubitus positioning

minimize compromise to airway and respiratory function. A Troop elevation pillow
may assist in head elevation.
If the patient develops vaginal bleeding and needs to undergo a speculum

examination, the lithotomy and Trendelenburg positions can reduce ventilation by
decreasing lung volume and increasing the work of breathing, but do increase
venous return and cardiac output. Therefore, patients should be appropriately

monitored during such examinations.
● Respiratory physiotherapy – Respiratory physiotherapy, including incentive

spirometry, can be helpful to reduce atelectasis. Noninvasive continuous positive
airway pressure is useful for patients preoperatively identified to have OHS or OSA.
(See "Strategies to reduce postoperative pulmonary complications in adults" and
"Noninvasive positive airway pressure therapy for the obesity hypoventilation
syndrome" and "Anesthesia for the patient with obesity", section on 'Post-anesthesia
care unit management'.)
● Early ambulation – Early ambulation may improve bowel function, as well as

decrease the risk of venous thrombosis. Physical therapy may be helpful for patients
with mobility limitations. As noted above, thromboprophylaxis is appropriate at least
until the patient is fully ambulatory. (See 'Prevention of venous thromboembolism'
above.)
Pain management — Specific approaches for postcesarean multimodal analgesia are

described in detail separately. An example of a protocol for postcesarean pain
management in hospitalized patients is shown in the table ( table 2). (See "Post-
cesarean delivery analgesia".)
Multimodal, opioid-sparing analgesia relies on various treatment modalities utilizing

multiple analgesics with different mechanisms of action and side effects. Using
multimodal analgesia seems to be the best approach to provide pain relief adequate to
support ambulation, allow the patient to be alert and energetic to care for the newborn,
minimize drug transfer into breast milk, and minimize side effects in both the mother and
newborn. Avoidance of unnecessary opioid exposure is important in all patients to
minimize risk for opioid use disorder.
In patients with a history of OSA or obesity hypoventilation syndrome (OHS), opioid-

related respiratory depression is an additional concern. Management of these patients is
reviewed separately. (See "Postoperative management of adults with obstructive sleep
apnea".)
Wound care
General care — If the incision is under the panniculus, placing clean rolled towels
beneath the panniculus postoperatively or an adhesive panniculus retractor improves air
circulation. Choice of dressing is reviewed separately. (See "Principles of abdominal wall
closure", section on 'Dressings'.)
Incisions should be closely monitored for signs of infection or disruption, even after the
patient leaves the hospital [43,74]. In one series of 194 patients with BMI ≥50 kg/m2 who
underwent cesarean birth, 30 percent had a wound complication: 90 percent were wound
disruptions and 86 percent were diagnosed after the patient was discharged from the
hospital [43].
The patient (or a household member) should check the incision daily for increasing
erythema or tenderness, drainage, or separation. This assessment can be complemented
by a wound check by a health care provider two to three days after discharge and again at
the time of suture removal. Telemedicine, including use of a smartphone application, can
be convenient and helpful for monitoring wound healing [75]. An optimum post-discharge
surveillance method has not been established [76].
Negative pressure wound therapy — We do not use negative pressure wound therapy
as part of postoperative wound care on our service as the overall value of the intervention
in patients with obesity undergoing cesarean birth remains unproven. Negative pressure
wound therapy may reduce surgical site infection (SSI), but experience with clean, closed
surgical wounds is limited and, among patients with severe obesity, there are few reports
of its use in postcesarean birth according to abdominal skin incision type.
In a meta-analysis of prophylactic negative pressure wound therapy versus standard care

after cesarean birth in patients with obesity (9 trials, 5529 participants), the intervention
reduced the risk of SSI compared with standard wound dressing (1.7 versus 8.3 percent;
relative risk [RR] 0.79, 95% CI 0.65-0.95) [77]. However, it did not reduce the rate of other
wound complications (eg, dehiscence, seroma, bleeding), readmission, or reoperation,
and it increased skin blistering. Limitations of the trials included practice variations in
surgical care (eg, skin antisepsis, incision type, skin closure technique, prophylactic
antibiotic timing and dose), inconsistent definitions regarding diagnosis and outcome,
lack of blinding and subjective judgment of some outcomes, and industry sponsorship of
some trials.
Further analysis and rigorous research are needed before prophylactic negative pressure
wound therapy can be routinely recommended for patients with obesity undergoing
cesarean birth, given the limitations of available data. Future trials should utilize best
practices for reducing SSIs and stratify randomization by risk (eg, scheduled versus
unscheduled cesarean birth). (See "Negative pressure wound therapy".)
SOCIETY GUIDELINE LINKS
Links to society and government-sponsored guidelines from selected countries and

regions around the world are provided separately. (See "Society guideline links: Cesarean
birth".)
SUMMARY AND RECOMMENDATIONS
● Risk assessment – Patients with obesity ( table 3) often have risk factors that
increase their morbidity from cesarean birth, including comorbidities ( table 1),
logistical challenges (eg, operating tables and equipment, intravenous [IV] and
epidural catheter placement), increased blood loss, and altered pharmacodynamics.
(See 'Factors to consider during surgical planning' above.)
● Risk mitigation – Key interventions to reduce risk include:
• Preparation – Preparation includes preoperative patient assessment for risk

factors for complications; use of aspiration, thromboembolism, and infection
prophylaxis; and availability and use of appropriate equipment. (See
'Preoperative evaluation and testing' above and 'Preoperative interventions to
reduce the risk of complications' above and 'Logistics' above.)
• Antibiotic prophylaxis – Antibiotic prophylaxis is based on the patient's weight

and risk status (planned versus intrapartum cesarean) (See 'Prevention of
surgical-site infection' above.)
All patients (assuming no allergy):
- ≥120 kg: cefazolin 3 g IV within the 60 minutes prior to surgical incision

- <120 kg: cefazolin 2 g IV within the 60 minutes prior to surgical incision
Patients with labor and/or rupture of membranes:
- Add azithromycin 500 mg IV
Patients with a history of true penicillin allergy (immediate hypersensitivity

reaction):
- IV clindamycin 900 mg plus gentamicin 5 mg/kg based on dosing weight
• Thromboprophylaxis – We apply an intermittent pneumatic compression device

sized to accommodate large legs preoperatively, and add pharmacologic
thromboprophylaxis postpartum once the patient is deemed stable from a
surgical/anesthesia standpoint. Choice of drug (unfractionated versus low
molecular weight heparin), timing of administration, dosing, and duration of
thromboprophylaxis (during hospitalization only versus for six weeks) are
reviewed separately. (See "Cesarean birth: Preoperative planning and patient
preparation", section on 'Thromboembolism prophylaxis'.)
● Anesthesia – As with patients without obesity, regional anesthesia is preferred in

most patients because it is typically safer than general anesthesia; however, the
choice between general and regional anesthesia should be guided by the urgency of
the case, requirements of the surgical procedure, and comorbidities. (See
'Anesthesia' above.)
● Procedure
• Landmarks – Abdominal soft tissue landmarks are often distorted in patients

with obesity. The umbilicus is often anatomically directly over or caudal to the
lower uterine segment because the large panniculus draws it caudally, whereas
the position of the symphysis pubis and iliac crests are reliable. (See 'Abdominal
wall incision' above.)
• Abdominal incision – For patients weighing less than 400 pounds (181 kg), we
make a Pfannenstiel incision if the panniculus can be adequately retracted
cephalad. For patients weighing 400 pounds (181 kg) pounds or more, we make a
transverse or vertical supraumbilical incision with the panniculus displaced
caudally. This weight threshold is based on personal experience and other
anecdotal evidence. (See 'Abdominal wall incision' above.)
• Hysterotomy incision – When possible, we make a low-transverse rather than a

low-vertical incision since the latter may extend into the upper uterine segment,
increasing the risk of uterine rupture in subsequent pregnancies. (See
'Hysterotomy incision' above and "Cesarean birth: Surgical technique", section on
'Choice of incision'.)
• Abdominal closure
- In patients with a midline fascial incision, we suggest a Smead-Jones or

comparable interrupted technique or mass continuous closure with
nonabsorbable or slowly absorbable suture ( figure 1) rather than a layered
closure (Grade 2C). We believe this is especially important for supraumbilical
incisions. Both approaches are equally effective for reducing the risk of
dehiscence or hernia formation.
In patients with a transverse fascial incision, a continuous nonlocking closure

with slowly absorbable #0 or 1 braided suture (eg, polyglactin 910) is a
common approach, but a monofilament (eg, polydioxanone) can also be
used. (See 'Fascial closure' above.)
- We recommend closure of subcutaneous tissue ≥2 cm thick (Grade 1B) and

we suggest not placing a subcutaneous drain (Grade 2C). (See 'Subcutaneous
closure' above and 'Drains' above.)
● Postpartum morbidity – Postoperative morbidities that are more common in

patients with obesity after cesarean birth include wound dehiscence and infection,
postpartum hemorrhage, thromboembolism, and pulmonary morbidity (particularly
in patients with obstructive sleep apnea [OSA] or obesity hypoventilation syndrome
[OHS]). (See "Obesity in pregnancy: Complications and maternal management",
section on 'Postpartum'.)
● Postoperative care
• Monitoring – All patients should undergo regular assessment of their level of

sedation and respiratory function during wakefulness and sleep. Respiratory
depression (eg, respiratory rate <8 to 10 breaths per minute, hypoxemia [oxygen
saturation ≤95 percent], hypercapnia), sedation, poor respiratory effort or quality,
snoring/noisy respiration, or desaturation are indications to rouse the patient

immediately and instruct them to take deep breaths. More invasive monitoring
(eg, pulse oximetry and capnography) or admission to a unit that can provide
continuous cardiopulmonary monitoring may be required. (See 'General
measures' above.)
• Pain management – As with patients without obesity, multimodal, opioid-

sparing analgesia is used for all patients. An example of a protocol for
postcesarean pain management in hospitalized patients is shown in the table
( table 2). (See "Post-cesarean delivery analgesia".)
• Wound management – If the incision is under the panniculus, placing clean

rolled towels beneath the panniculus postoperatively or an adhesive panniculus
retractor improves air circulation. Incisions are closely monitored for signs of
infection or disruption, which are more common in patients with obesity. Routine
prophylactic negative pressure wound therapy is not required. (See 'Negative
pressure wound therapy' above.)
Use of UpToDate is subject to the Terms of Use.
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Topic 4452 Version 72.0
GRAPHICS
Health risks associated with obesity
Coronary artery disease, hypertension
Hyperlipidemia
Type II diabetes mellitus
Asthma, obesity hypoventilation syndrome, obstructive sleep apnea
Gastroesophageal reflux, esophagitis
Fatty liver, cholelithiasis, non-alcoholic steatohepatitis (NASH), cirrhosis
Stress urinary incontinence
Venous stasis disease, deep vein thrombosis, pulmonary embolus, superficial thrombophlebitis
Hernias (inguinal, ventral, umbilical, incisional)
Irregular menstruation, hirsutism, gynecomastia, infertility, polycystic ovary syndrome
Cancer (colon, prostate, uterine, breast)
Infection (cellulitis, panniculitis, postoperative wound infections)
Degenerative joint disease, osteoarthritis
Pseudotumor cerebri (idiopathic intracranial hypertension)
Clinical depression
Courtesy of Vivian Sanchez, MD and Edward Mun, MD.
Graphic 69532 Version 2.0
Mass closure of abdominal incisions
(A) Smead-Jones closure. Far-far-near-near. Suture passes laterally

through rectus sheath and peritoneum and adjacent fat. The suture
crosses midline to pick up medial edge of fascia on opposite side of
incision.
(B) Alternative closure. Far-near-near-far. The far bite is 1 to 1.5 cm
away from the edge. The near bite is 5 mm from the edge.
(C) Running mass closure. Two sutures are used, beginning from each
pole of the incision. Sutures are 1 cm away from edge and 1 cm apart.
The sutures are tied at the midpoint of the incision.
Courtesy of Therese Trenhaile, MD.
Example of a protocol for post-cesarean delivery pain management in

hospital
Nonopioid analgesics for all patients
Acetaminophen 1 g IV intraoperative
plus
650 mg every 6 hours, or 1 g every 8 hours, orally or IV,
postoperative
NSAIDs Ketorolac 15 to 30 mg IV intraoperative; for weight <50 kg,

maximum dose 15 mg
plus
Ibuprofen 600 mg every 6 hours or 800 mg every 8 hours
orally, or ketorolac 15 mg IV every 6 hours for 48 to 72 hours
postoperative
Patients who have neuraxial anesthesia
Neuraxial opioid Preservative-free opioid:

Morphine 100 to 150 mcg intrathecal (preferred) or
3 mg epidural after delivery*
OR
Hydromorphone 50 to 75 mcg intrathecal or
0.4 to 1 mg epidural after delivery*
Oral opioid Oxycodone 2.5 to 5 mg orally every 4 hours as needed for

breakthrough pain:
VNPS 1 to 4/10: 2.5 mg, repeat in 1 hour if needed ¶
VNPS >4/10: 5 mg, repeat in 1 hour if needed ¶
Patients who have general anesthesia, or neuraxial anesthesia without

neuraxial opioid
Nerve block Bilateral TAP or QL block:
OR 0.25% bupivacaine 20 mL per side
Wound infiltration OR
0.2% ropivacaine 20 mL per side
OR
Liposomal bupivacaine 1.3% 10 mL plus 0.25% aqueous
bupivacaine 20 mL per side Δ
Wound infiltration: Subfascial (preferred) or subcutaneous wound
catheter, 0.5% bupivacaine or ropivacaine 4 to 5 mL/hour
Opioids IV PCA with morphine or hydromorphone for up to 24 hours,

transitioned to oxycodone as above by postoperative day one:
Morphine – demand dose 2 mg, lockout interval 10
minutes, without continuous (basal) infusion
Hydromorphone – demand dose 0.4 mg, lockout interval 8
minutes, without continuous (basal) infusion
OR
Oral oxycodone as above, with bolus IV opioids available for
breakthrough pain
For severe or ongoing pain, options

Rescue nerve block Bilateral TAP or QL block as above: 0.25% bupivacaine or 0.2%
ropivacaine; consider liposomal bupivacaine
Opioids Fentanyl 25 to 50 mcg IV every 5 minutes, to maximum of 200

mcg until pain relief or if associated sedation, oxygen
saturation <95%, or serious event occurs, such as hypotension
(in PACU only)
OR
Morphine 1 to 3 mg IV every 5 minutes until pain relief or if
associated sedation, oxygen saturation <95%, or serious event
occurs, such as hypotension (in PACU only); if analgesia is
insufficient after total approximately 20 mg, review overall
pain control regimen
OR
Hydromorphone 0.2 to 0.5 mg IV every 5 minutes until pain
relief or if associated sedation, oxygen saturation <95%, or
serious event occurs, such as hypotension (in PACU only); if
analgesia is insufficient after approximately 3 mg, review
overall pain control regimen
OR
IV PCA as above
Nonopioid adjuncts Gabapentin 200 mg orally every 8 hours for 5 doses; enhanced
respiratory monitoring may be necessary
This protocol would be applicable for patients without particular risk factors for severe
postoperative pain (eg, chronic pain, opioid tolerant). For further detail, refer to UpToDate
content on post-cesarean delivery analgesia.
IV: intravenous; NSAIDs: nonsteroidal anti-inflammatory drugs; VNPS: verbal numerical pain
score; TAP: transversus abdominus plane; QL: quadratus lumborum; PCA: patient-controlled
analgesia; PACU: post-anesthesia care unit.
* For patients who have combined spinal epidural anesthesia, intrathecal morphine is
preferred, rather than epidural morphine, to minimize opioid dose and systemic absorption.
¶ When nursing resources are available, the use of "split-dose" opioid order sets can reduce
total opioid consumption.
Δ When liposomal bupivacaine is mixed with aqueous bupivacaine, the dose of bupivacaine
must be <50% of the dose of liposomal bupivacaine. Liposomal bupivacaine should not be
mixed with other local anesthetics except for aqueous bupivacaine.
Classification of body mass index
Underweight – BMI <18.5 kg/m 2
Normal weight – BMI ≥18.5 to 24.9 kg/m 2
Overweight – BMI ≥25 to 29.9 kg/m 2
Obesity – BMI ≥30 kg/m 2
Obesity class 1 – BMI 30 to 34.9 kg/m 2
Obesity class 2 – BMI 35 to 39.9 kg/m 2
Obesity class 3 – BMI ≥40 kg/m 2
BMI classifications are based upon risk of cardiovascular disease. These classifications for BMI
have been adopted by the NIH and WHO for White, Hispanic, and Black individuals. Because
these cutoffs underestimate risk in the Asian population, the WHO and NIH guidelines for
Asian individuals define overweight as a BMI between 23 and 24.9 kg/m 2 and obesity as a BMI
>25 kg/m 2 . Some investigators employ four classes of obesity such that class 3 is defined as
BMI 40 to 49.9 kg/m 2 and super obesity is defined as BMI ≥50 kg/m 2 .
BMI: body mass index; NIH: National Institutes of Health; WHO: World Health Organization.
References:
1. 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.
2. Obesity: Preventing and managing the global epidemic. Report of a WHO consultation. World Health Organ
Tech Rep Ser 2000; 894:i.
3. WHO Expert Consultation. Appropriate body mass index for Asian populations and its implications for policy
and intervention strategies. Lancet 2004; 363:157.
Contributor Disclosures
Richard P Porreco, MD No relevant financial relationship(s) with ineligible companies to
disclose. Jean-Ju Sheen, MD No relevant financial relationship(s) with ineligible companies to
disclose. David L Hepner, MD Grant/Research/Clinical Trial Support: Pharmacosmos [ERAS-driven
Elective Surgery]. Consultant/Advisory Boards: Pharmacosmos [IV Iron-Associated Hypophosphatemia
]. All of the relevant financial relationships listed have been mitigated. William Grobman, MD No
relevant financial relationship(s) with ineligible companies to disclose. Vanessa A Barss, MD,
FACOG No relevant financial relationship(s) with ineligible companies to disclose.
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these
are addressed by vetting through a multi-level review process, and through requirements for
references to be provided to support the content. Appropriately referenced content is required of all
authors and must conform to UpToDate standards of evidence.
Conflict of interest policy

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Cesarean birth: Overview of issues for patients with obesity - UpToDate 07/04/2023 05:07

Official reprint from UpToDate®

Cesarean birth: Overview of issues for patients with

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

● (See "Cesarean birth: Surgical technique".)

● (See "Obesity in pregnancy: Complications and maternal management".)

FACTORS TO CONSIDER DURING SURGICAL PLANNING

● Baseline health hazards – Obesity is associated with numerous health hazards

● Perioperative respiratory dysfunction – Obstructive sleep apnea (OSA) and obesity

● Difficulty placing intravenous lines – Peripheral intravenous (IV) lines may be

● Difficulty placing neuraxial anesthesia – Placement of neuraxial needles and

● Altered pharmacodynamics – Pharmacodynamics may be altered because patients

PREOPERATIVE EVALUATION AND TESTING

Scheduling the consultation in the early to mid-third trimester is prudent in case of

● Electrocardiogram – The decision to obtain an ECG should be individualized, taking

morbidity (coronary heart disease, congestive heart failure, cerebrovascular disease,

● Perioperative respiratory function – Preoperative identification of OSA helps in

PREOPERATIVE INTERVENTIONS TO REDUCE THE RISK OF

Prevention of aspiration — Both pregnancy and elevated BMI are consistently associated

section on 'Preparation for anesthesia'.)

Prevention of venous thromboembolism — We suggest application of an intermittent

Thromboprophylaxis is typically recommended for patients with obesity undergoing

Prevention of surgical-site infection — Important components of infection prophylaxis

Evidence — The value of preincision antibiotic prophylaxis for cesarean birth has

● Higher dosing – Standard doses of antimicrobial agents, particularly the

In 2013, guidelines developed jointly by the American Society of Health-System

By comparison, the American College of Obstetricians and Gynecologists (ACOG)

● Extended-spectrum dosing – Emerging data support use of extended-spectrum

● Postpartum antibiotics – Traditionally, prophylaxis has not been continued

Anesthesia issues of patients with obesity are reviewed in detail separately:

● (See "Anesthesia for the patient with obesity".)

● Patient positioning – Patient positioning is important to limit unfavorable

● Blood pressure monitoring – Blood pressure must be monitored with an

hypertension in adults", section on 'Cuff size'). If external measurements are not

● Intermittent pneumatic compression devices – Intermittent pneumatic

● Surgical exposure – A removable adhesive panniculus retractor/retention system or

The panniculus retractor/retention system may be left in place postoperatively to

● Transverse or vertical? – The choice of incision should be based on the surgeon's

• Suprapubic low-transverse incision – The adipose tissue two finger-breadths

A disadvantage of making an incision under the panniculus is that the wound

- Vertical – A vertical supraumbilical incision is another option, when the

A disadvantage of supraumbilical incisions is that exposure to the lower uterine

Hysterotomy incision — We prefer a transverse incision in the lower uterine segment

The classic Smead-Jones technique (far-far-near-near) or an alternative approach

abdominal wall closure".)

Subcutaneous closure — The subcutaneous adipose layer should be closed when the

Drains — Subcutaneous drains are not recommended, as randomized trials show no clear

maternal management", section on 'Postpartum'.)

● Close monitoring – Patients with obesity require close postoperative monitoring

● Positioning – Both a head-up, 30-degree position and lateral decubitus positioning

If the patient develops vaginal bleeding and needs to undergo a speculum

venous return and cardiac output. Therefore, patients should be appropriately

● Respiratory physiotherapy – Respiratory physiotherapy, including incentive

● Early ambulation – Early ambulation may improve bowel function, as well as

Pain management — Specific approaches for postcesarean multimodal analgesia are

Multimodal, opioid-sparing analgesia relies on various treatment modalities utilizing

In patients with a history of OSA or obesity hypoventilation syndrome (OHS), opioid-

In a meta-analysis of prophylactic negative pressure wound therapy versus standard care