Subcuticular Suture for Cesarean Skin Incision Closure

In the United States cesarean delivery rates in 2012 were 32.8%. The incidence of wound
complications post-cesarean delivery has been quoted to be anywhere from 3-30%. Wound
complications can include surgical site infection (SSI), hematoma, seroma, and wound
separation. Risk factors for wound complications include elevated body mass index (BMI),
prolonged duration of surgery, maternal diabetes, coexisting infection (chorioamnionitis),
anemia, and increasing number of prior cesarean deliveries. The majority of cesarean
deliveries are performed through a suprapubic low-transverse skin incision (Pfannenstiel
incision). The incidence of wound complication post-cesarean comparing suture and staple skin
closure has been extensively studied with the over all conclusion recommending suture skin
closer.

A comparison of the type of suture used for skin closer and wound complication has not been
widely studied. Vats et al. compared three types of suture material in post-cesarean wound
complication and found statistical difference in wound discomfort, swelling and induration,
wound discharge, and wound dehiscence. Their quoted wound complication rate was as high as
thirty-three percent. Although, their study population was limited to emergent cesarean
deliveries, the sample size was small, and their method of randomization was not explained.

Physiologic wound healing involves five steps: inflammation, granulation, epithelialization,
wound contraction, and scar maturation. These biologic processes overlap in occurrence but
happen in a defined order. Investigators hypothesize that suture materials with differing
profiles will have different effects on these biologic processes. The two most widely used
sutures for low-transverse cesarean skin incision closure in our institution are
poliglecaprone 25 and polyglactin 910. Poliglecaprone 25 (monocryl) is a monofilament suture
with an absorption profile of 91-119 days. Polyglactin 910 (coated vicryl) is a braided
suture with an absorption profile of 56-70 days. Given the difference in profile for each
suture and the physiologic wound healing process investigators question which would be more
effective for wound healing.

The purpose of the study:

1. To compare poliglecaprone 25 and polyglactin 910 suture in Pfannenstiel incision closure
for prevention of wound complication (SSI, hematoma, seroma, wound separation).

2. To determine if risk factors for wound complication should guide the choice of suture
used for closure of Pfannenstiel incision.

Methods Patient enrollment will occur during their admission to labor and delivery. Patients
will be approached if they meet the enrollment criteria. If they agree to participate in the
trial a pre-randomized sequentially numbered, opaque, sealed envelope will be assigned to
them and opened at the time of cesarean delivery which will assign the surgical suture to be
used for skin closure.

Inclusion criteria for the trial:

1. Gestational age of 37 completed weeks or greater based on their estimated due date
calculated from last menstrual period or early ultrasound.

2. Scheduled cesarean delivery or...

3. Non-emergent cesarean delivery

Patients participating will be undergoing either:

1. Scheduled cesarean delivery

2. Non-emergent cesarean delivery

Non-emergent cesarean delivery will be defined as an indicated cesarean delivery based on
obstetrical criteria without significant fetal heart tracing abnormalities. This would
include women diagnosed with a labor dystocia or arrest of labor, failed labor induction,
fetal malpresentation in labor (i.e. breech presentation) or any other non-emergent
indication for cesarean delivery in which there is no immediate danger to mother or fetus.

The following exclusion criteria will be used:

1. Urogenital tract infection within 2 weeks prior to surgery

2. Chronic oral or injectable steroid use (> 2 weeks)

3. Emergency cesarean delivery (need to deliver immediately due to a maternal or fetal
indication)

4. Vertical skin incision

5. Participation in another research study

The patients will be randomized after informed consent is obtained into two groups.

Group 1: Incision closure with poliglecaprone 25 suture Group 2: Incision closure with
polyglactin 910 suture

Randomization for the study will be generated using www.randomization.com, in blocks of 6 and
10 prior to the start of enrollment for the trial. Sequentially numbered, opaque, sealed
envelopes will contain the surgical suture to be used for skin closure, poliglecaprone 25 or
polyglactin 910.

Surgical preparation will follow departmental protocol. Once the patient is randomized to a
suture group the corresponding suture will be pulled and placed on the sterile field for use
after completion of the cesarean in accordance to manufacturer's guidelines. Cesarean
delivery will occur following the technique of the surgeon. Maternal demographics to be
obtained will include BMI, gestational age, pre and postoperative day #1 complete blood
count, estimated blood loss, type of preoperative skin preparation, surgical time from skin
incision to closure, birth weight, Apgar scores, newborn outcome, indication for cesarean
delivery, medical history and any antenatal complications, past surgical history,
postoperative course, and intraoperative or postoperative complications. Wound complication
will be defined as wound separation of ≥ 1 cm in length, hematoma or seroma (serous fluid
collection or subcutaneous blood collection), and surgical site infection defined by the
Center for Disease Control (CDC) guidelines. The primary outcome will include a composite
finding of a wound complication in the 30 day period post-operatively.

All patients will be followed until the routine postpartum visit occurs at 6-8 weeks
following delivery with their primary prenatal care provider. Postpartum visit information
will be extracted from the medical record. All patients will receive a follow up telephone
call at post-operative day 30 or greater to monitor any post-operative complications as
listed above.

An alert notification will be placed in each patient's medical record that they are enrolled
in this study and close monitoring and documentation of the cesarean incision is necessary.
The definition of wound complication as listed in the first paragraph above will be included
in the alert notification to standardize reporting for each patient.

Recruitment Mechanisms Clinicians will ask patients during admission to labor and delivery
after they meet enrollment criteria whether they are interested in the study. Consent will
then be obtained by the research clinicians.

Informed Consent Patient consent will occur on admission to the labor and delivery unit. The
capacity of each patient to provide ethically adequate informed consent will be assessed by
the PI or his designee. It is possible that patients will be enrolled during labor prior to
cesarean section if not in significant pain although the majority of patients will be
presenting for scheduled cesarean sections prior to labor. Consent will be obtained from
women in active labor after labor analgesia has occurred. Emergency cesareans are excluded.

Inclusion Criteria:

- Gestational age of 37 completed weeks or greater based on their estimated due date
calculated from last menstrual period or early ultrasound.

- Patients participating will be undergoing either:

- Scheduled cesarean delivery

- Non-emergent cesarean delivery

Exclusion Criteria:

- Urogenital tract infection within 2 weeks prior to surgery

- Chronic oral or injectable steroid use (> 2 weeks)

- Emergency cesarean delivery (need to deliver immediately due to a maternal or fetal
indication)

- Vertical skin incision

- Active participation in another research study