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Management of cesarean delivery in the morbidly obese woman

Overview: Obese women have increased rate of cesarean delivery and complications. Specialized equipment and anesthetic considerations may be necessary. Transverse skin incisions and closure of the subcutaneous tissue may decrease the risk of wound complications. Perioperative DVT prophylaxis should be considered. 

Objective: To describe special considerations and the best operative technique to prevent adverse outcomes in obese women undergoing a cesarean delivery

Diagnosis/definition: Obesity is defined as BMI ≥30 kg/m2 and further categorized as Class I: BMI 30-34.9 kg/m2, Class II: 35-39.9 kg/m2, and Class III: ≥40 kg/m2.2 Other terms used include severe (or morbid) obesity for those with BMI ≥40 kg/m2 and super (or super-morbid) obesity for BMI > 50 kg/m2 .

Epidemiology/Incidence: More than 35% of the population is obese and obstetricians encounter the problem with increasing frequency. 

Complications: Compared with women of normal BMI, obese women have twice the rate of primary cesarean delivery, emergency cesarean delivery, and wound infection. Anesthesia also carries additional risks in the setting of obesity. 

Management: Physicians should be aware that most hospital equipment has weight limits. Specialized equipment may be needed based on a patient's weight, physical dimensions, or both. Anesthesia carries additional risks in obese, and an anesthesiology consultation should be considered for women who are obese. Further testing (such as an EKG or evaluation for sleep apnea) may be necessary. Retrospective data suggest that vertical incisions are actually associated with increased rather than decreased risk of wound complications compared with transverse incisions. Standard doses of antibiotics are less likely to achieve therapeutic tissue levels in obese patients, so in an obese woman, 2 g of cefazolin is recommended rather than 1 g. Drainage of the incision does not decrease wound complications, whereas closure of the subcutaneous (SQ) tissue in women with a fat thickness greater than 2 cm reduced wound disruption by 34%. Compared to suturing of the skin incision, the risk of either a wound infection or separation was two-fold higher with staple closure. Obesity and cesarean delivery are both risk factors for deep vein thrombosis so either mechanical or pharmacologic or both thromboprophylaxis should be considered.

Last Reaffirmed: Aug 1, 2016