Wound Infection After Cesarean: Effect of

Subcutaneous Tissue Thickness

STEPHEN T. VERMILLION, MD, CARLOS LAMOUTTE, MD, DAVID E. SOPER, MD,
AND ANA VERDEJA, MD
Objective: To estimate the effect of the thickness of subcutaneous tissue at the surgery site on abdominal wound
infection after cesarean delivery.
Methods: We measured the maximum vertical depths of
subcutaneous incisions of women who had cesarean deliveries. The surgical technique for closure was standardized
and drains were not used. Abdominal wound infection was
defined by standard criteria and limited to the first 6 postoperative weeks. Additional demographic, intrapartum, and
perioperative data previously associated with wound infection also were collected. Data were analyzed by Student t
test, 2 test, and multiple logistic regression.
Results: Wound infection occurred in 11 of 140 women
(7.8%) who delivered by cesarean. Risk factors identified as
significantly associated with wound infection by univariate
analysis were thickness of subcutaneous tissue, maternal
weight, and body mass index. Multiple logistic regression
analysis confirmed subcutaneous tissue thickness as the
only significant risk factor for wound infection, with a
relative risk of 2.8 (95% confidence interval 1.3, 5.9). There
were no significant differences between women who developed wound infections and those without infections in
terms of selected demographics, duration of ruptured membranes, number of vaginal examinations, chorioamnionitis,
type of skin incision, or duration of surgery.
Conclusion: Thickness of subcutaneous tissue appears to
be the only significant risk factor associated with abdominal
wound infection after cesarean delivery. (Obstet Gynecol
2000;95:923 6. 2000 by The American College of Obstetricians and Gynecologists.)

Wound infection after cesarean delivery is a serious complication that can increase postpartum morbidity, length
of hospital stay, and cost. Wound infection has been
reported in 216% of all women who have cesareans.13
Potential risk factors that are unique to cesarean delivery
include preexisting intra-amniotic infection, perioperative
antibiotic use, presence or duration of ruptured membranes, number of vaginal examinations, and elective or
From the Department of Obstetrics and Gynecology, Medical University of South Carolina, Charleston, South Carolina.

VOL. 95, NO. 6, PART 1, JUNE 2000

emergency reason for the surgery.4 The thickness of subcutaneous tissue also was a significant risk factor for
wound infection after abdominal hysterectomy, but has
not been evaluated in women delivered by cesarean.5
We designed a prospective study to estimate the
effect of thickness of subcutaneous tissue and other
variables reported as risk factors for wound infection in
women who delivered by cesarean.

Materials and Methods

Women who had cesarean deliveries at the Medical
University of South Carolina between June 1996 and
August 1997 were eligible. The study was approved by
the Institutional Review Board. Written informed consent was obtained from all participants. All operations
were done by obstetric residents with the assistance of
one of the coauthors. Pfannenstiel incisions were done
on all patients except for those with previous vertical
incisions, in whom repeat vertical incisions were used.
Hair on the abdominal skin was shaved immediately
before preparation of the surgical site. The skin was
prepared with either povidone-iodine or 4% chlorhexidine gluconate solution, depending on iodine sensitivity. The same scalpel was used for incising the skin and
subcutaneous tissue. The maximum thickness of the
subcutaneous tissue was measured in centimeters before we entered the peritoneal cavity. Antibiotic prophylaxis of 1 g of intravenous cefazolin was given to
each woman when the umbilical cord was clamped. The
placenta was removed with gentle traction and exterior
massage of the uterus, and removed manually only if it
was retained for more than 5 minutes. Whenever possible, the uterus was exteriorized for hysterotomy repair. Wounds were irrigated thoroughly with sterile
saline before closure. Sutures and drains were not used
in the subcutaneous tissue. Pfannenstiel skin incisions
were closed with subcuticular 3-0 vicryl, whereas vertical skin incisions were closed with staples.
Wound infection was diagnosed when a wound drained

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923

Table 1. Demographic and Intrapartum Variables

Variable
Age (y)
Race
Black
White
Parity
Multiparous
Nulliparous
Duration of ROM (min)
Median
Range
Vaginal examinations
Chorioamnionitis

Table 2. Perioperative Data

Uninfected
(n 129)

Infected
(n 11)

26.9 6.4

29.1 7.2

NS

68 (53%)
61 (47%)

6 (54%)
5 (46%)

NS
NS

41 (32%)
61 (48%)

3 (27%)
4 (36%)

NS
NS

120
0 24,480
2.6 2.3
8 (6%)

165
0 2880
2.9 2.3
1 (9%)

NS
NS
NS

NS not significant; ROM rupture of membranes.

Data are presented as mean standard deviation or n (%).

purulent material or serosanguinous fluid, associated with

induration, warmth, and tenderness. Suspected wound
infections were opened for confirmation. Wounds were
examined twice daily during hospitalization for evidence
of infection. After discharge, women were instructed
about the signs and symptoms of wound infection, given
written instruction sheets with a diary for symptom documentation, and instructed to contact one of the coauthors
immediately if any listed symptoms appeared. Women
who contacted the investigators about symptoms were
examined by one of the coauthors within 12 hours. All
participants were examined 2 and 6 weeks after surgery.
We also collected demographic data and intrapartum
data, including presence or duration of ruptured membranes, number of vaginal examinations, presence of
chorioamnionitis, reason for cesarean, and skin incision
types. Chorioamnionitis was defined as three of four of
the following signs without other causative factors:
maternal fever (at least 38C), uterine tenderness, maternal tachycardia (more than 120 beats per minute), and
fetal tachycardia (more than 160 beats per minute).
To detect a 15% difference in the frequency of wound
infection between women with less than 3 cm of subcutaneous tissue and those with at least 3 cm, with .05 and
.1, we determined that 120 subjects would be needed
in our sample. Discrete data were tested for significance
using 2 or Fisher exact tests. Continuous data were tested
for significance with a two-tailed t test with P .05
considered significant. To determine the potential confounding effect of multiple variables, a multiple logistic
regression analysis was done. Variables considered risk
factors for wound infection after cesarean delivery were
included in univariate and logistic regression analyses.

Results
Wound infection was diagnosed in 11 of 140 women
(7.8%) after cesarean. The demographic and intrapartum

924 Vermillion et al

Infection After Cesarean

Variable
Thickness of subcutaneous
tissue (cm)
Height (cm)
Weight (kg)
Body mass index (kg/m2)
Operative time (min)
Skin incision
Pfannenstiel
Vertical
Uterine incision
Low transverse
Classic uterine
Type of cesarean
Elective
Unscheduled

Uninfected
(n 129)

Infected
(n 11)

2.3 1.2

4.1 1.8

.04

161.3 7.9
82.8 18.6
44.5 2.1
59.5 16.6

159.8 11.5
99.4 33.3
49.7 6.3
71.1 18.4

NS
.002
.001
NS

119 (22%)
10 (8%)

8 (72%)
3 (28%)

NS
NS

102 (79%)
27 (21%)

7 (63%)
4 (36%)

NS
NS

20 (16%)
109 (85%)

1 (9%)
10 (91%)

NS
NS

NS not significant.
Data are presented as mean standard deviation or n (%).

variables of infected and uninfected groups are listed in

Table 1. The groups were similar in selected demographic
characteristics, presence or duration of ruptured membranes, number of vaginal examinations, and frequency of
chorioamnionitis. Perioperative data are shown in Table 2.
Univariate analysis showed a significantly greater subcutaneous tissue thickness, maternal weight, and body mass
index (BMI) in infected women compared with uninfected
women. The groups were similar in type of skin and
uterine incisions, elective or unscheduled cesareans, and
operation times. The median length of hospital stay for all
subjects was 4 days, ranging from 2 to 7 days.
Multiple logistic regression analysis confirmed that
only a single independent risk factormaximum thickness of subcutaneous tissuewas significantly associated with abdominal wound infection after cesarean,
with a relative risk (RR) of 2.8 (95% confidence interval
[CI] 1.3, 5.9). Whereas nine of 11 infected women
(81.8%) had subcutaneous tissue depths greater than
3 cm, 38 of 129 women (29.5%) who were not infected
had thicknesses greater than 3 cm.
Aerobic cultures were available from the exudate of
five of 11 cases that met the criteria for wound infections. Escherichia coli was isolated from two cultures,
Enterococcus species from two cultures, and both E coli
and Enterococcus species from one culture. Anaerobic
and mycoplasma cultures were not collected.

Discussion
Obesity has long been regarded as a risk factor for
abdominal wound infection.6 10 However, obesity has
been equated with an overall increase in weight and not
specifically with the patients habitus. When obesity
was calculated anthropometrically using skin-fold

Obstetrics & Gynecology

thickness, no significant association with wound infection could be found.11 Our data suggest that increased
weight or BMI does not specifically increase patients
risks of wound infection, but that the thickness of
subcutaneous tissue at the site of the incision does.
Thus, a larger and heavier woman with the same
subcutaneous tissue thickness of a smaller and lighter
woman would have the same risk of wound infection.
Our findings are similar to those reported by Soper et
al5 from a sample of women who had abdominal
hysterectomies, in which subcutaneous tissue thickness
was the most significant risk factor for wound infection.
It is widely accepted that ischemic wounds heal
poorly because of limited perfusion and delivery of
fibroblasts and leukocytes. Previous investigators
found that wounds with large unapproximated areas or
dead space remained relatively hypoxic.12 Large unapproximated surfaces also might accumulate serosanginous fluid, which can act as an ideal culture
medium for contaminating pathogens. Greater subcutaneous tissue thicknesses increase the likelihood of
such an environment and might explain the association
with wound infection seen in our study.
Other identifiable risk factors for wound infection
after cesarean delivery have included increased vaginal
examinations, prolonged rupture of membranes, and
emergency surgeries.13,14 However, we were unable to
confirm such associations in our population. The predominant pathogens isolated from a few of the wound
infections in our population were E coli and Enterococcus
species, which are consistent with the findings of previous investigators.15,16
Identifying subcutaneous tissue thickness as a significant risk factor for postoperative wound infection after
cesarean is not useful as a diagnostic test. In our study,
the positive predictive value of subcutaneous tissue
thickness of at least 3 cm was only 19% (nine of 47), with
a negative predictive value of 98% (91 of 93). Most
women with subcutaneous tissue measurements of at
least 3 cm will not have wound infections more than
80% of the time.
Several mechanical prevention strategies for wound
infection have been studied, including closed-suction
drainage and closure of the subcutaneous tissue, with
varying degrees of success.3,17 Soisson et al18 conducted
a randomized trial of subcutaneous retention sutures
versus skin closure alone in women with subcutaneous
tissue thickness of at least 5 cm after gynecologic
laparotomy. In that study, the investigators found a
significant reduction in the frequency of superficial
wound separation in women with retention sutures.18
Perioperative antibiotic prophylaxis during cesarean
has been widely accepted, but increasing resistance
among bacterial pathogens soon might limit obstetri-

VOL. 95, NO. 6, PART 1, JUNE 2000

cians options for wound-infection prophylaxis. Perhaps with the evolution of many antibiotic-resistant
pathogens, the focus of wound-infection prevention
might change to mechanical strategies in which subcutaneous tissue thickness will be important. On the basis
of the findings in the present study, we are currently
conducting a randomized trial of closed-suction drainage versus observation after cesarean for the prevention
of wound infection in women with a subcutaneous
tissue depth of at least 4 cm.

References
1. Emmons SL, Krohn M, Jackson M, Eschenbach DA. Development
of wound infections among women undergoing cesarean section.
Obstet Gynecol 1988;72:559 64.
2. Webster J. Post-caesarean wound infection: A review of the risk
factors. Aust N Z J Obstet Gynaecol 1988;28:201 6.
3. Loong RLC, Rogers MS, Chang AMZ. A controlled trial on wound
drainage in caesarean section. Aust N Z J Obstet Gynaecol 1988;
28:266 9.
4. Gibbs RS, Blanco JD, St Clair PJ. A case-control study of wound
abscess after cesarean delivery. Obstet Gynecol 1983;62:498 501.
5. Soper DE, Bump RC, Hurt WG. Wound infection after abdominal
hysterectomy: Effect of the depth of subcutaneous tissue. Am J
Obstet Gynecol 1995;173:46571.
6. Pitkin RM. Abdominal hysterectomy in obese women. Surg Gynecol Obstet 1976;142:532 6.
7. Davidson AIG, Clark C, Smith G. Postoperative wound infection:
A computer analysis. Br J Surg 1971;58:3337.
8. Garrow JS, Hastings EJ, Cox AG, North WR, Gibson M, Thomas
TM, et al. Obesity and postoperative complications of abdominal
operation. BMJ 1988;297:181 6.
9. Cruse PJE, Foord R. A five-year prospective study of 23,649
surgical wounds. Arch Surg 1973;107:206 10.
10. Beattie PG, Rings TR, Hunter MF, Lake Y. Risk factors for wound
infection following caesarean section. Aust N Z J Obstet Gynaecol
1994;34:398 402.
11. Shapiro M, Munoz A, Tager IB, Schoenbaum SC, Polk BF. Risk
factors for infection at the operative site after abdominal or vaginal
hysterectomy. N Engl J Med 1982;307:1661 6.
12. Kivisaari J, Vihersaari T, Renvall S, Niinikoski J. Energy metabolism of experimental wounds at various oxygen environments.
Ann Surg 1975;181:823 8.
13. Martens MG, Kolrud BL, Faro S, Maccato M, Hammill H. Development of wound infection or separation after cesarean delivery.
Prospective evaluation of 2,431 cases. J Reprod Med 1995;40:1715.
14. Nice C, Feeney A, Godwin P, Mohanraj M, Edwards A, Baldwin A,
et al. A prospective audit of wound infection rates after caesarean
section at five West Yorkshire hospitals. J Hosp Infect 1996;33:5561.
15. Roberts S, Maccato M, Faro S, Pinell P. The microbiology of
post-cesarean wound morbidity. Obstet Gynecol 1993;81:383 6.
16. Sherman D, Lurie S, Betzer M, Pinhasi Y, Arieli S, Boldur I. Uterine
flora at cesarean and its relationship to postpartum endometritis.
Obstet Gynecol 1999;94:78791.
17. Del Valle GO, Combs P, Qualls C, Curet LB. Does closure of the
camper fascia reduce the incidence of post-cesarean superficial
wound disruption? Obstet Gynecol 1992;80:1013 6.
18. Soisson AP, Olt G, Soper JT, Berchuck A, Rodriguez G, ClarkePearson DL. Prevention of superficial wound separation with
subcutaneous retention sutures. Gynecol Oncol 1993;51:330 4.

Vermillion et al

Infection After Cesarean

925

Address reprint requests to:

Stephen T. Vermillion, MD
Department of Obstetrics and Gynecology
Medical University of South Carolina
96 Jonathan Lucas Street, Suite 634
PO Box 250619
Charleston, SC 29425
E-mail: vermills@musc.edu

926 Vermillion et al

Infection After Cesarean

Received August 12, 1999.

Received in revised form November 19, 1999.
Accepted December 2, 1999.

Copyright 2000 by The American College of Obstetricians and

Gynecologists. Published by Elsevier Science Inc.

Obstetrics & Gynecology