Cohen vs Pfannenstiel cesarean skin incision for body mass index ≥35 kg/m2: a randomized controlled trial

• Published in: American journal of obstetrics & gynecology MFM 2024-12, Vol.6 (12), p.101528, Article 101528
• Main Authors: McCurdy, Rebekah J., Harding, Siani, Felder, Laura, Beáta, Anita, Schnatz, Peter, Berghella, Vincenzo
• Format: Article
• Language: English
• Subjects: Cesarean delivery; obesity; random; skin incision
• ISSN: 2589-9333; 2589-9333
• DOI: 10.1016/j.ajogmf.2024.101528

Maternal obesity is recognized as a significant risk factor for adverse pregnancy outcomes, including increased cesarean delivery rates and heightened surgical complications. It is unclear whether the Cohen or Pfannenstiel skin incisions for cesarean delivery are associated with different outcomes. This study aimed to evaluate the effect of a Cohen or Pfannenstiel cesarean skin incision on maternal morbidity. Pregnant individuals with a body mass index of ≥35 kg/m2, carrying either singleton or multiple pregnancies, were consented prenatally and in labor. Eligible participants who underwent a cesarean delivery between 24 and 41 weeks of gestation were randomized to either the Pfannenstiel or Cohen skin incision group at Thomas Jefferson University Hospital from October 2016 to March 2020. This study aimed to recruit 284 participants based on a sample size calculation, assuming a 50% reduction in wound complications with Cohen vs Pfannenstiel incisions (80% power; α=.05). However, recruitment was terminated early after 72 participants were randomized. The primary outcome was a composite maternal morbidity within 6 weeks, which consisted of the following: wound infection, hematoma, seroma, separation of skin of ≥1 cm, readmission for wound complications, endometritis, and postpartum hemorrhage. Statistical analyses included bivariate tests, t tests, and nonparametric analyses. Of 331 pregnant individuals who consented prenatally and in labor, 72 eventually underwent cesarean delivery and were randomized, 34 to the Cohen skin incision group and 38 to the Pfannenstiel skin incision group. The mean body mass index was >42 kg/m2. Approximately two-thirds of the patients had a pannus, 56% of the patients were Black, 47% of the patients had diabetes mellitus, and 56% of the patients had hypertensive disorders. The primary outcome of composite maternal morbidity occurred in 47.1% of patients in the Cohen incision group and 36.8% of patients in the Pfannenstiel incision group (risk ratio, 1.24; 95% confidence interval, 0.71–2.08) and was similar regardless of the presence of a pannus or degree of obesity. Surgical site infection, hematoma, seroma, wound separation/dehiscence, endometritis, and postpartum hemorrhage were similar between the Cohen and Pfannenstiel groups. In addition, neonatal outcomes were similar between the Cohen and Pfannenstiel groups, except that the Cohen incision group was found to have a statistically significantly lower Apgar score at 5 minu