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 helps to reduce these risks and ensure optimal maternal and newborn outcomes.

Issues relating to cesarean birth of the patient with obesity will be discussed here. General issues relating to cesarean birth, the numerous maternal and perinatal risks of obesity during pregnancy and the immediate postpartum period, and anesthetic and surgical issues in individuals with obesity are reviewed separately:

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

●(See "Cesarean birth: Surgical technique and wound care".)

●(See "Cesarean birth: Postoperative issues".)

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

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

PERIOPERATIVE CONSIDERATIONS — The following factors increase morbidity in patients with obesity undergoing cesarean birth; the relative contribution of each factor has not been clearly defined [1-9]:

●Obesity is associated with numerous health hazards (table 1). (See "Overweight and obesity in adults: Health consequences".)

●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. Preanesthesia evaluation and other issues related to anesthesia and postoperative care of patients with obesity are discussed separately. (See "Preanesthesia medical evaluation of the patient with obesity" and "Anesthesia for the patient with obesity".)

●Obesity increases the probability of both scheduled and emergency cesarean birth. (See "Obesity in pregnancy: Complications and maternal management", section on 'Cesarean birth'.)

●Surgery in patients with obesity may require specialized equipment (eg, high-weight-capacity operating tables, 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'.)

●Peripheral intravenous lines may be difficult to place due to subcutaneous adiposity; central venous access may be needed if peripheral access is tenuous. (See "Principles of ultrasound-guided venous access".)

●Placement of neuraxial needles and catheters can be difficult because the usual anatomic landmarks are obscured, the patient may be unable to flex their back adequately, and the distance from skin to target is longer than normal. Although the rate of successful neuraxial anesthesia is similar for pregnant patients with severe obesity and those without obesity, initial placement requires more attempts and repeated placement is more common due to epidural failure [10,11]. (See "Anesthesia for the patient with obesity", section on 'Neuraxial anesthesia'.)

●Mask ventilation may be difficult and intubation may be difficult or fail. (See "Anesthesia for the patient with obesity", section on 'Difficulty with airway management'.)

●Incision-to-delivery time and total operative time are longer.

●Blood loss is increased, but blood transfusion requirements are not clearly higher.

●Pharmacodynamics may be altered because patients with obesity have a larger 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'.)

●Postoperatively, patients with obesity are at increased risk of wound infection and disruption, endometritis, and thromboembolism compared with patients with normal weight. (See "Obesity in pregnancy: Complications and maternal management", section on 'Postpartum'.)

PREOPERATIVE EVALUATION AND TESTING — Ideally, patients with obesity should have an antepartum consultation with the anesthesia team. Scheduling the consultation in the early to mid-third trimester is prudent in case of preterm birth. Preoperative history, physical examination, and selective testing can identify patients with comorbidities, such as a difficult airway or obstructive sleep apnea (OSA), that increase their risk of complications during and following surgery. (See "Preanesthesia medical evaluation of the patient with obesity".)

Preoperative testing should be guided by patient-specific risk factors. Some clinicians choose to crossmatch these patients rather than order a type and screen, or they hold a clot in case crossmatch is needed [12]. The most cost-effective approach is unclear, as high-quality data are not available.

It is also unclear whether an electrocardiogram (ECG) should be performed routinely. The American Heart Association (AHA) 2009 scientific advisory on cardiovascular evaluation and management of patients with body mass index ≥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 and chronic renal insufficiency with creatinine levels >2.0 mg/dL) or poor exercise tolerance [13]. 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 [14,15]. (See "Preoperative medical evaluation of the healthy adult patient", section on 'Electrocardiogram'.)

Preoperative identification of OSA helps in planning interventions to reduce respiratory morbidity, which can be aggravated by immobility, positioning, pain, and use of opioids. Polysomnography is not mandatory to exclude OSA. Clinical questionnaires or prediction scores can be used for screening in the general population but are poorly predictive in pregnant people and not routinely used for screening in pregnancy. (See "Obstructive sleep apnea in pregnancy" and "Surgical risk and the preoperative evaluation and management of adults with obstructive sleep apnea" and "Postoperative management of adults with obstructive sleep apnea".)

INTERVENTIONS TO REDUCE THE RISK OF POSTOPERATIVE COMPLICATIONS

Thromboprophylaxis — Thromboprophylaxis is recommended for patients with obesity undergoing cesarean birth, given that pregnancy, cesarean birth, and obesity are all risk factors for postpartum venous thrombosis. Pregnant people undergoing cesarean birth in the United States generally receive mechanical prophylaxis. Pneumatic compression devices should be sized to accommodate large legs. Many experts also recommend pharmacologic thromboprophylaxis for patients with obesity. Specific recommendations for thromboprophylaxis are reviewed separately. (See "Cesarean birth: Preoperative planning and patient preparation", section on 'Thromboembolism prophylaxis'.)

Surgical-site infection prevention — Important components of infection prophylaxis include using aseptic practices, minimizing duration of surgery, antibiotic prophylaxis, and preoperative optimum glycemic control in patients with diabetes [16]. A detailed 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 — The abdomen and vagina are prepped with an antiseptic solution. Skin preparation with chlorhexidine-alcohol and vaginal preparation with chlorhexidine gluconate or povidone-iodine are reasonable options. (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

●Broad spectrum – For patients with obesity undergoing cesarean birth at average risk of infection, dosing is based on weight as follows:

•Patients ≥120 kg: cefazolin 3 g intravenously (IV) preoperatively

•Patients <120 kg: cefazolin 2 g IV preoperatively

●Extended-spectrum – Local SSI rates should determine whether an extended-spectrum regiment should be administered to all patients with obesity or limited to those with additional risk factors for SSI (eg, labor, rupture of membranes, immunosuppression, pregestational diabetes). The author does not use an extended-spectrum regimen or administer postoperative antibiotics routinely because the rate of SSI in his patients with obesity is low with cefazolin alone. However, he considers the following reasonable options for patients with obesity in hospitals with high SSI rates when cefazolin alone is administered:

•Cefazolin 2 or 3 g IV plus azithromycin 500 mg IV preoperatively, or

•Cefazolin 2 or 3 g IV preoperatively then cephalexin 500 mg orally plus metronidazole 500 mg orally every 8 hours for 48 hours following cesarean birth

The preoperative antibiotics should be administered within the 60 minutes before making the incision. (See "Cesarean birth: Preoperative planning and patient preparation", section on 'Antibiotic prophylaxis'.)

The evidence supporting these approaches is reviewed below. (See 'Evidence' below.)

Penicillin allergy — For patients with a history of serious penicillin allergy (immediate hypersensitivity reaction), combination therapy with clindamycin 900 mg plus gentamicin 5 mg/kg based on dosing weight intravenously provides broad coverage [17]. Gentamicin dosing is based on the patient's actual body weight; however, if the patient's actual weight is more than 20 percent above ideal body weight (IBW), the dosing weight (DW) is determined as follows (calculator 1) [17]:

Evidence — The value of preincision antibiotic prophylaxis 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. Standard doses of antimicrobial agents, particularly the cephalosporins [18,19], 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 [18]); therefore, higher doses of the prophylactic antimicrobial agent should be administered [20]. 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 grams for patients ≥120 kg undergoing cesarean birth and 2 grams for patients <120 kg [17,21]. 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".)

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), but this has not become a standard of care, in part because of concerns about inducing antibiotic resistance and the effect on the newborn microbiome. (See "Cesarean birth: Preoperative planning and patient preparation", section on 'Regimen'.)

Traditionally, prophylaxis has not been continued postpartum because studies in general surgical populations showed no benefit from postoperative antimicrobial prophylaxis [17]. However, a randomized trial in patients with obesity (body mass index [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 grams intravenous preoperative cefazolin prophylaxis) reported a reduction in SSIs (6.4 versus 15.4 percent, relative risk 0.41, 95% CI 0.22-0.77; number needed to treat to prevent one SSI: 12) [22]. The frequency of SSI in the control group was quite high and the dose of intravenous 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 (the SSI rate in the author's hospital is 4 percent) and patients with obesity who receive a higher dose of intravenous cefazolin. This trial should prompt further study to confirm/refute these findings, determine whether specific subpopulations of patients with obesity are more/less likely to experience clinically meaningful benefits (eg, longer operative time, BMI >50 kg/m²), and evaluate maternal, infant, and societal risks other than serious adverse events and allergic reactions [23].

Prevention of aspiration — Both pregnancy and elevated BMI are consistently associated with higher rates of gastroesophageal reflux. Measures to reduce the risk of aspiration are similar to those in patients without obesity. (See "Anesthesia for the patient with obesity", section on 'Aspiration prophylaxis' and "Anesthesia for cesarean delivery", section on 'Preparation for anesthesia'.)

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 [10]. Therefore, as discussed above, antepartum consultation with the anesthesia team is recommended. Scheduling the consultation in the early to mid-third trimester is prudent in case of preterm birth.

The choice between general and regional anesthesia should be guided by the 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 [24,25]. 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 separately:

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

●(See "Anesthesia for cesarean delivery".)

●(See "Airway management for the pregnant patient".)

OPERATIVE PROCEDURE

Positioning and equipment — 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. 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).

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 [26]. Given the increased potential for supine hypotension during surgery from the combined effects of the panniculus, gravid uterus, and regional anesthesia, we suggest tilting the operating table at least 15 degrees to the left or using a firm right lumbar wedge of sufficient height to achieve at least 15 degrees of tilt. A 2010 systematic review of randomized trials did not demonstrate a clear maternal or fetal benefit from use of these maneuvers, possibly because of small sample size, inadequate tilt, or a heterogeneous patient population [27].

Blood pressure should 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.

As discussed above, pneumatic compression devices should be sized to accommodate large legs. Long instruments and wide deep retractors (including panniculus retractors) are usually required to access structures deep in the pelvis.

Fetal heart rate monitoring in the preoperative area can be achieved with a device that uses five abdominal ECG electrodes to monitor the fetal ECG (AN24, Monica Healthcare) and is minimally affected by body mass index (BMI) [28].

Abdominal wall incision — The patient's body habitus, including weight distribution and panniculus size, should be carefully assessed before deciding upon the appropriate incision. The type of incision may affect exposure, ease of newborn delivery, postoperative pain and respiratory effort, wound strength, and wound complication rates.

Whether a transverse or midline (vertical) incision is superior for the pregnant patient with obesity remains controversial, as no randomized trials have compared different types of incisions in these patients. Some retrospective studies have reported higher wound complication rates in patients with midline (vertical) incisions than in those who underwent a transverse incision (wound infection: vertical incision 35 to 46 percent; transverse incision 9 to 21 percent) [29-31]. 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 [8,32-34].

When making the skin incision, a key factor is awareness that the location of soft tissue landmarks may be atypical. In patients with an apron-like panniculus, the umbilicus is a poor landmark for identifying 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. The pubic symphysis and iliac crests are reliable landmarks regardless of maternal body habitus [35].

A large incision is especially important in the pregnant patient with obesity because uterine exposure may be suboptimal with a small incision, the fetus is likely to be large, and it is difficult to manually stretch the incision because of the thick abdominal wall.

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).

Options — Incision options include:

●Suprapubic incisions – 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 400 pounds (181 kg), elevating the panniculus and retracting it cephalad with Elastoplast tape or Montgomery straps attached to a bed rail allows placement of a low transverse (eg, Pfannenstiel) or low midline (vertical) incision [36]. Some type of mechanical aid may be needed due to the enormous size of the panniculus [37]. Retracting an extremely large panniculus onto the thorax has been associated with cardiopulmonary compromise (hypotension, hypoxia). A case report described pressure necrosis of the panniculus from prolonged digital retraction [37].

A disadvantage of making an incision under the panniculus is that the wound must heal in a warm, moist environment with high bacterial colonization, thus potentially increasing the risk of infection.

●Supraumbilical incisions – For patients who weigh over 400 pounds (181 kg), and particularly those over 600 pounds (272 kg), a transverse supraumbilical incision has several advantages: it has the strength of the transverse repair, avoids burying the wound under a large panniculus, and provides excellent abdominal exposure [7]. However, it has not been proven to be less morbid than a Pfannenstiel incision [29,38]. In the author's series of 11 supraumbilical incisions for cesarean births in patients weighing 268 to 540 pounds (BMI 40 to 73 kg/m²), nine patients had no surgical site complications, one developed an incarcerated umbilical hernia, and one developed periumbilical external wound separation.

Another option is a midline (vertical) supraumbilical incision, with the panniculus displaced caudally [39]. If this is done, the umbilicus should not be used as a landmark for estimating the location of pelvic organs. The pubic symphysis and iliac crests are more reliable [35].

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 delivering the fetus as a breech.

Tubal sterilization (including salpingectomies), if desired, is easily achieved with this incision.

An alternative suprapannicular incision technique that displaces the panniculus caudad has been described in a series of 17 patients; the authors state that it preserves access to the lower uterine segment and a potential low transverse hysterotomy [40].

Hysterotomy — 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. (See "Cesarean birth: Surgical technique and wound care", section on 'Low vertical and classical incisions' and "Uterine rupture: After previous cesarean birth".)

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 delivery as a breech or use of a forceps blade or vacuum device. (See "Cesarean birth: Management of deeply engaged, impacted and floating fetal presentations".)

Fascial closure — Mass closure of vertical incisions reduces the risk of dehiscence and hernia formation. The classic Smead-Jones technique (far-far-near-near) or an alternative approach (far-near-near-far) are acceptable methods (figure 1) [41]. 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 [42-44]. Our preference is 0-polypropylene nonabsorbable suture. A delayed absorbable suture, such as loop 0-PDS or 1-PDS, is an acceptable alternative. 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 [45]. Inverted knots keep knot stacks out of the subcutaneous tissues. (See "Principles of abdominal wall closure".)

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 [46,47]. 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, but not in those <2 cm [47].

Drains — Subcutaneous drains are not recommended, as randomized trials consistently show that they do not decrease the risk of wound complications in the overall obstetric population [48,49] or in patients with obesity [30,50,51]. 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 [52].

Skin closure — The author generally uses staples for reapproximating the skin, but has successfully used subcuticular polypropylene sutures, both for infrapannicular and supraumbilical incisions.

Although practice in the overall obstetric population has shifted toward suture rather than staple closure, there are limited data on the effect of skin closure method on the incidence of wound complications in patients with obesity who undergo cesarean birth. A randomized trial of staples versus subcuticular suture for skin closure in patients with class III obesity (BMI ≥40 kg/m²) undergoing cesarean birth found no significant difference between groups in composite wound complication rates, which were 19.3 and 17.6 percent, respectively [53]. Another trial reported a trend toward reduction in composite wound complication rates (20.0 versus 27.6 percent) and a reduction in surgical site infection (10.5 versus 22.7 percent) [54].

A trial that randomly assigned patients with obesity undergoing cesarean birth to nonabsorbable polypropylene interrupted mattress sutures or subcuticular suture did not provide convincing evidence favoring one approach over the other [55]. (See "Cesarean birth: Surgical technique and wound care", section on 'Skin closure'.)

POSTOPERATIVE CARE — Postpartum morbidities more common in patients with obesity after cesarean birth include wound dehiscence and infection [4], postpartum hemorrhage [56], thromboembolism [57,58], and pulmonary morbidity (particularly in patients with obstructive sleep apnea [OSA] or obesity hypoventilation syndrome [OHS]) [12]. (See "Obesity in pregnancy: Complications and maternal management", section on 'Postpartum'.)

General measures — Patients with obesity require close postoperative monitoring. Those with OSA, OHS, or significant cardiac disease should be admitted to a unit that can provide continuous cardiopulmonary monitoring for as long as it is needed, generally 24 hours. Fluid intake and output should also be monitored closely to maintain euvolemia, especially in patients with cardiopulmonary disease.

In addition to routine assessment of vital signs, use of continuous pulse oximetry and capnography (where available) can detect impaired oxygenation and ventilation, respectively. 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 her to take deep breaths [59]. Patients should be closely monitored until recovery of respiratory function.

Both a head-up, 30-degree position and lateral decubitus positioning minimize compromise to airway and respiratory function. Early ambulation and respiratory physiotherapy, including incentive spirometry, can also be helpful. 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 may also 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 'Thromboprophylaxis' above.)

If the patient develops vaginal bleeding and needs to undergo a speculum examination, the lithotomy and Trendelenburg positions increase venous return and cardiac output, but can reduce ventilation by decreasing lung volume and increasing the work of breathing.

Wound care — If the incision is under the panniculus, placing clean rolled towels beneath the panniculus postoperatively helps allow air circulation.

Negative pressure wound therapy — We do not use negative pressure wound therapy as part of postoperative wound care on our service as our surgical site infection (SSI) rate is relatively low, the devices are expensive, and the overall value of the intervention in patients with obesity undergoing cesarean birth remains unproven. Negative pressure wound therapy may reduce SSI, but experience with clean, closed surgical wounds is limited and, among patients with severe obesity, there are few reports of its use 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; RR 0.79, 95% CI 0.65-0.95) [60]. 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, stratify by risk (eg, scheduled versus unscheduled cesarean birth), and adjust for known confounders, including type of incision. (See "Negative pressure wound therapy".)

Pain control — Multimodal, balanced 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 a newborn, minimize drug transfer into breast milk, and minimize side effects in both the mother and newborn.

Multimodal analgesia using local anesthetics via the neuraxial route and oral nonsteroidal anti-inflammatory drugs (NSAIDs) is the safest approach. A goal in all patients is to avoid unnecessary opioid exposure and minimize risk for addiction. This is particularly important in patients with a history of OSA or OHS, as opioids may exacerbate respiratory depression. However, many postpartum floors do not have the capacity to monitor patients with a neuraxial catheter.

When opioids are needed to provide adequate pain control, use of multimodal analgesia allows a reduction in the dose. In a 2010 meta-analysis of randomized trials evaluating multimodal therapy with acetaminophen, NSAIDs, or cyclooxygenase (COX)-2 inhibitors for postoperative pain, all of these agents reduced the consumption of morphine [61]. Options include ketorolac 30 mg IV every six hours, ibuprofen 600 mg orally four times a day or 800 mg three times a day, or acetaminophen 1 gm IV or orally every six hours.

Opioids can be administered via oral, parenteral, and neuraxial routes. Practice guidelines for obstetric anesthesia [62] recommend neuraxial opioids for postpartum analgesia following cesarean birth. Neuraxial opioids are preferred over parenteral opioids because they minimize the risk of respiratory depression and provide better analgesia. Patient-controlled analgesia is an option in cases where a general anesthetic was used for the operative procedure. Neuraxial administration does not eliminate the risk of respiratory depression, which has been reported in patients with severe obesity who received intrathecal opioids for postcesarean analgesia [63]. When opioids are administered postoperatively, patients should be closely monitored with continuous pulse oximetry (eg, hourly in the first 24 hours and every two hours in the second 24 hours after cesarean [64]). Many institutions keep patients with obesity on the labor floor for 24 hours following the use of neuraxial opioids for postoperative analgesia.

Local and systemic preventive approaches can be effective, and offer advantages in specific clinical situations (see "Management of acute perioperative pain", section on 'Preventive analgesia'). However, preemptive systemic administration unnecessarily exposes the fetus/neonate to drugs, which is undesirable. Local infiltration of the surgical site at the end of the cesarean avoids this problem, but offers only relatively mild, short-term analgesia and still has the potential for systemic toxicity.

Continuous preperitoneal wound infusion of local anesthetic is another investigational approach [65-68]. In a blinded randomized trial in patients undergoing cesarean birth, catheter wound infusion did not improve pain scores with movement at 24 hours compared with placebo, but patients with severe obesity were excluded and an important secondary endpoint (opioid use at 24 to 48 hours) showed a trend toward decreased use (difference in median consumption -12.5 mg, 95% CI -30 to 5) [68]. This author continues to use continuous ropivacaine infusions subfascially based on observational data suggesting it reduces opioid use dramatically postoperatively. Because of the mass closure in the supraumbilical approach, the catheter is placed subcutaneously, which may increase leakage.

Specific drug regimens for postcesarean analgesia are described separately (see "Anesthesia for cesarean delivery", section on 'Post-cesarean delivery analgesia'). Some medications (eg, ketorolac, aspirin, opioids [especially tramadol and codeine]) can be of concern in breastfed infants and should be avoided or used at the lowest dose for the shortest period of time while monitoring the infant for adverse effects. (See "Overview of the postpartum period: Normal physiology and routine maternal care", section on 'Safety of common analgesics in breastfeeding women'.)

Monitoring for wound complications — Incisions should be closely monitored for signs of infection or disruption, even after the patient leaves the hospital [30,69]. In one series of 194 patients with body mass index ≥50 kg/m² who underwent cesarean birth, 30 percent had a wound complication [30]. Ninety percent were wound disruptions and 86 percent were diagnosed after the patient was discharged from the hospital.

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

●Patients with obesity (table 2) may have additional health hazards that affect their morbidity from cesarean birth. Cesarean birth of these patients often requires modifying equipment, anesthesia and analgesia, and surgical technique to ensure an optimal outcome. (See 'Perioperative considerations' above.)

●We suggest antepartum consultation with the anesthesia team, as challenges and complications related to anesthesia are more common in patients with obesity. (See 'Anesthesia' above and 'Preoperative evaluation and testing' above.)

●We recommend antibiotic prophylaxis for all patients undergoing cesarean birth (Grade 1A). We use cefazolin 2 grams for patients <120 kg and 3 grams for patients ≥120 kg, in the absence of penicillin allergy. For patients with a history of serious penicillin allergy (immediate hypersensitivity reaction), intravenous clindamycin 900 mg plus gentamicin 5 mg/kg based on dosing weight provides broad coverage. Since the author has a low rate of surgical site infection in his practice, he does not administer an extended-spectrum antibiotic regimen (eg, cefazolin plus azithromycin) to patients in labor or with ruptured membranes and he does not administer postoperative antibiotic prophylaxis, but one of these approaches may be reasonable in practices with high rates of postoperative infection in patients who receive cefazolin alone. (See 'Surgical-site infection prevention' above.)

●We suggest thromboprophylaxis (Grade 2C). We use mechanical thromboprophylaxis in all patients; the addition of pharmacologic thromboprophylaxis depends on patient specific factors. (See 'Thromboprophylaxis' above.)

●The choice between general and regional anesthesia should be guided by the requirements of the surgical procedure and comorbidities. Regional anesthesia is recommended for most patients. (See 'Anesthesia' above.)

●When making the skin incision, attention to the distorted landmarks in patients with obesity is very important. The umbilicus is often anatomically directly over or caudal to the lower uterine segment because the large panniculus draws it caudally; however, the position of the symphysis pubis and iliac crests are reliable. (See 'Abdominal wall incision' above.)

●For patients who weigh <400 pounds (181 kg), we suggest a Pfannenstiel incision if the panniculus can be adequately retracted cephalad (Grade 2C). For patients who weigh over 400 pounds (181 kg), we suggest a transverse or vertical supraumbilical incision with the panniculus displaced caudally (Grade 2C). (See 'Options' above.)

●For hysterotomy, we prefer a transverse incision in the lower uterine segment because it is associated with the lowest rate of uterine rupture in subsequent pregnancies. (See 'Hysterotomy' above.)

●The fascia can be closed using a Smead-Jones or comparable interrupted technique or mass continuous closure with nonabsorbable or slowly absorbable suture. This is especially important for supraumbilical incisions. Both approaches are equally effective for reducing the risk of dehiscence or hernia formation. (See 'Fascial closure' above.)

●We recommend closure of subcutaneous tissue ≥2 cm thick (Grade 1A). We also recommend avoiding placement of subcutaneous drains (Grade 1A). (See 'Subcutaneous closure' above.)

●We do not use prophylactic negative pressure wound therapy following cesarean birth in patients with obesity. (See 'Negative pressure wound therapy' above.)

●Postoperatively, fluid intake and output should be monitored to maintain euvolemia. 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 her to take deep breaths. Patients should be closely monitored until recovery of respiratory function. (See 'General measures' above.)