Cesarean Delivery: Original Research

Prophylactic Negative Pressure Wound

Therapy and Wound Complication After
Cesarean Delivery in Women With Class II or
III Obesity
A Randomized Controlled Trial
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Kristina A. Wihbey, MD, Ellen M. Joyce, MD, Zachary T. Spalding, MD, Hayley J. Jones, MD,
Todd A. MacKenzie, PhD, Rebecca H. Evans, MD, June L. Fung, PhD, Marlene B. Goldman, MS, ScD,
and Elisabeth Erekson, MD, MPH

OBJECTIVE: To compare the occurrence of superficial
surgical site infections in obese women using prophy-
lactic negative pressure therapy with standard dressings
after cesarean delivery.
Methods: We conducted a randomized controlled, non-
blinded, two-center study of prophylactic negative pres-
sure therapy compared with standard surgical dressings
placed at the time of primary closure at cesarean delivery
in obese women with body mass indexes (BMI) of 35 or
higher (ie, class II and III obesity). Our primary outcome
was occurrence of a superficial surgical site infection. We
assumed a superficial surgical site infection occurrence
rate of 20% and intended to recruit 400 women.
However, after low enrollment of 166 women over 24
From the Departments of Obstetrics and Gynecology and Biomedical Data
Science and the Dartmouth Institute for Health Policy and Clinical Practice, the
Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire.
The devices used in this study were provided by an unrestricted research grant
from KCI Medical (San Antonio, Texas). KCI Medical had no role in the study
design, data collection, or data analysis. Final results of the study were shared
with the company before manuscript submission; however, the investigators were
not bound to incorporate KCI’s comments. The authors’ decision as to what the
manuscript contained was final.
Each author has indicated that he or she has met the journal’s requirements for
authorship.
Received February 6, 2018. Received in revised form May 4, 2018. Accepted May
15, 2018.
Corresponding author: Kristina A. Wihbey, MD, Department of Obstetrics and
Gynecology, The Geisel School of Medicine at Dartmouth, 189 N Main Street,
Concord, NH 03301; email: kwihbey@crhc.org.
Financial Disclosure
The authors did not report any potential conflicts of interest.
© 2018 by the American College of Obstetricians and Gynecologists. Published
by Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0029-7844/18
months, an interim analysis for futility was conducted
and the decision was made to halt the study.
RESULTS: Women were recruited between January 5,
2015, and January 7, 2017, from two sites. The mean BMI
on admission was 44.9 (68) for the prophylactic negative
wound therapy group and 43.4 (67) for the standard dress-
ing group. There were no differences in the occurrence of
observed superficial surgical site infections between
women using prophylactic negative pressure wound ther-
apy (12/80 [15%]) compared with women who received the
standard dressing (8/81 [10%], P5.35, relative risk 1.52, 95%
CI 0.66–3.52). There were no differences in the occurrence
of composite wound complications between women using
prophylactic negative pressure wound therapy (25/80
[31%]) compared with women who received the standard
dressing (24/81 [30%], P5.87).
CONCLUSION: In this randomized controlled trial that
did not achieve full anticipated enrollment, we did not
observe a decrease in superficial surgical site infections
after cesarean delivery in obese women with the use of
prophylactic negative pressure wound therapy.
CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov,
NCT02390401.
(Obstet Gynecol 2018;132:377–84)
DOI: 10.1097/AOG.0000000000002744
T he prevalence of obesity (defined as body mass
index [BMI, calculated as weight (kg)/[height
(m)]2] 30 or higher) continues to increase, affecting
approximately 40% of adult females in the United
States according to Centers for Disease Control and
Prevention 2013–2014 statistics.1 Obesity has a signif-
icant effect on many aspects of pregnancy, including

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increased need for cesarean delivery. In addition, obe-
sity is a well-recognized risk factor for the develop-
ment of postoperative surgical site infections and
other wound complication.2,3 In the late 1990s, Tran
et al4 found a 9.8% surgical site infection rate among
obese women after cesarean delivery with risk of
infection doubling for every five-unit increment of
BMI.
Prophylactic negative pressure wound therapy
as a means of reducing wound infection has been
explored as primary dressings in the orthopedic and
cardiothoracic fields, but limited data have been
published in the peer-reviewed literature report on
use with abdominal incisions. Two meta-analyses
recently combined published peer-reviewed manu-
scripts, meeting abstracts, and data published on
intranet websites to determine the effectiveness of
prophylactic negative pressure wound therapy at
the time of cesarean delivery.5,6 Unfortunately,
these two meta-analyses reported conflicting data
on the effectiveness of prophylactic negative
pressure.
Therefore, the objective of this randomized con-
trolled trial was to compare the occurrence of
superficial surgical site infections in women with class
II or III obesity as defined by the Centers for Disease
Control and Prevention using prophylactic negative
pressure wound therapy compared with standard
dressings after cesarean delivery.
MATERIALS AND METHODS
We conducted a randomized controlled, nonblinded,
multicenter study of prophylactic negative pressure
wound therapy compared with standard surgical
dressings placed at the time of primary closure in
a cesarean delivery. Institutional review board
approval was obtained from the Dartmouth Commit-
tee for the Protection of Human Subjects on April 21,
2015 (#00005211) and from the Southern New
Hampshire Medical Center Clinical Trials Office
(#2015-01). This trial was registered with clinical-
trials.gov (Clinical Trial Registration:
NCT02390401). Women were recruited and con-
sented to participate in this study before the onset of
active labor during any routine prenatal visit or inpa-
tient admission.
Women were recruited from two hospitals,
Dartmouth-Hitchcock Medical Center (a rural tertiary
care center with a level III neonatal intensive care
unit) and Southern New Hampshire Medical Center
(a community-based hospital with a level II neonatal
intensive care unit).

Fig. 1. Flow diagram.

Wihbey. Prophylactic Negative Pressure Wound Therapy. Obstet Gynecol 2018.

378 Wihbey et al Prophylactic Negative Pressure Wound Therapy OBSTETRICS & GYNECOLOGY

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 Women were eligible for inclusion if they under- Table 1. Demographics and Characteristics of
went cesarean delivery for a viable neonate and their Participating Women
BMI on admission to the labor and delivery floor was
35 or higher. All women undergoing cesarean deliv- NPWT Standard
Dressing Dressing
ery were eligible for inclusion. Women were ap- Characteristic (n580) (n586)
proached only for participation and consent in this
study before active labor Additionally, women who Site
were younger than 18 years old, did not speak A 64 (80) 72 (84)
B 16 (20) 14 (16)
English, had an allergy to silver or adhesives products,
Maternal characteristics
or who had a skin incision that would not fit the Maternal age (y) 31.066 30.265
device or standard dressing (eg, “T” skin incision) Race
were excluded. White 76 (99) 81 (99)
Abdominal preparation for cesarean delivery was Black 1 (1) 0 (0.0)
Other 0 (0) 1 (1)
performed with 2% chlorhexidine alcohol solution.
Ethnicity
All women received intravenous antibiotics before Hispanic 2 (2) 0 (0)
skin incision consistent with American College of Parity
Obstetricians and Gynecologists’ guidelines7 with the 1 20 (25) 34 (40)
majority of women receiving cefazolin or clindamycin 2 37 (46) 23 (27)
3 18 (23) 23 (27)
with gentamicin if allergic. Surgical techniques were
4 or more 5 (6) 6 (7)
left to the discretion of the surgeon. Women were Gestational age (wk)
discharged postoperatively by the primary team, usu- 28 or less 1 (1) 3 (3)
ally on the third or fourth postoperative day, irrespec- Greater than 28–37 21 (29) 17 (22)
tive of study assignment. All women were scheduled Greater than 37–42 51 (70) 59 (74)
Greater than 42 0 (0) 0 (0)
to return for a wound assessment on postoperative
Multiple gestation 4 (5) 5 (6)
day 5–7. Prior cesarean deliveries
If randomized to prophylactic negative pressure 0 38 (48) 44 (51)
wound therapy, the device was applied at the time of 1 33 (41) 30 (35)
primary skin closure at cesarean delivery. It was 2 7 (9) 11 (13)
3 or more 2 (3) 1 (1)
placed over the closed surgical incision under sterile
BMI (kg/m2) 44.968 43.467
conditions and was removed between postoperative BMI category (kg/m2)
day 5 and 7 at the time of incision check. 35–40 30 (38) 31 (38)
The standard dressing after cesarean delivery was Higher than 40 to 50 31 (39) 40 (49)
also applied using a sterile technique. If subcuticular Higher than 50 19 (24) 15 (19)
Preoperative hct (%) 30.4610 31.369
closure was used, sterile slim adhesive strips (also
Preoperative anemia (hct less than 58 (73) 54 (63)
known as Steri-Strips) were applied. For both sub- 36%)
cuticular and staple closure, the dressing consisted of Antenatal steroids 8 (10) 11 (13)
a sterile nonadherent wound dressing (also known as Diabetes mellitus
Telfa), a sterile gauze, and a waterproof transparent Type I diabetes mellitus 1 (1) 1 (1)
Type II diabetes mellitus 9 (12) 4 (5)
adhesive dressing (also known as Tegaderm). The
Gestational diabetes mellitus 11 (15) 20 (25)
standard dressing was removed on postoperative day Hypertension
2. Chronic hypertension 6 (8) 4 (5)
A randomization program (www.randomization. Gestational hypertension 6 (8) 3 (4)
com, Alberta, Canada) was used to generate sealed Preeclampsia with severe features 6 (8) 9 (11)
Current smoker 14 (18) 13 (15)
opaque envelopes with study assignment. Women
were randomized at the conclusion of the cesarean NPWT, prophylactic negative pressure wound therapy; BMI, body
mass index; hct, hematocrit.
delivery, during skin closure, when the envelopes Data are n (%) or mean6SD.
were opened by a circulating operating room nurse.
Two randomization strata were created using per-
muted blocks with varying block sizes for women with Our primary outcome was occurrence of super-
BMIs from 35 to less than 40 and women with BMIs ficial surgical site infection, defined according to
of 40 or higher and for each site to ensure equal dis- Centers for Disease Control and Prevention criteria8
tribution of study allocation across these two separate as infection involving only the skin or subcutaneous
BMI categories and sites. tissue occurring within 30 days of surgery with at least

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Table 2. Intrapartum and Intraoperative Characteristics of Participating Women

Intrapartum Event NPWT Dressing (n580) Standard Dressing (n586)

Reason for admission to labor and delivery

Spontaneous labor 51 (65) 54 (65)
Induction of labor 18 (23) 22 (27)
Scheduled cesarean delivery 9 (12) 7 (8)
Duration of rupture of membranes (min) 2116407 2266440
Duration of rupture of membranes (h)
Less than 18 74 (93) 76 (88)
18 or more 6 (8) 10 (12)
Chorioamnionitis 1 (1) 0 (0)
Intraoperative variables
Operative time (incision to stop, min) 82.3625 80.4623
Type of anesthesia
Spinal–epidural 71 (89) 79 (93)
General 9 (11) 6 (7)
Skin incision
Pfannenstiel 55 (86.0) 68 (93.2)
Vertical midline 9 (14) 5 (7)
Skin closure
Subcuticular 58 (91) 67 (93)
Staples 6 (9) 5 (7)
Estimated blood loss (mL) 9366253 9666318
Postpartum hemorrhage (greater than 1,000 mL) 38 (48) 39 (45)
Intraoperative blood transfusion 0 (0) 3 (4)
Maternal procedures with delivery
Tubal ligation 29 (36) 21 (24)
Peripartum hysterectomy 0 (0) 0 (0)
NPWT, prophylactic negative pressure wound therapy.
Data are n (%) or mean6SD.

one of the following: 1) purulent drainage from the
wound or 2) organism identified by culture or wound
deliberately opened by the surgeon. Patients also
needed to have at least one of the following symp-
toms: pain, swelling, or erythema. Our secondary
outcome was a composite wound complication,
including superficial, deep, or organ-space surgical
site infection; wound dehiscence; seroma; or hema-
toma that occurred within 30 days of surgery. Other
secondary outcomes included 30-day readmission,
30-day reoperation, and need for antibiotic treatment
for any reason (eg, mastitis, urinary tract infection,
pyelonephritis). We also examined length of stay
after cesarean delivery and rates of breastfeeding at
discharge this seems to have been erroneously dupli-
cated. We had already stated this earlier in the text.
Additional outcomes were determined by chart
review.
Standard statistical methods such as frequency
distributions and measures of central tendency were
used to evaluate the demographic and clinical
characteristics of the participants. Pearson x2, Fisher
exact test, and Student t test for parametric distrib-
uted variables and Kruskal-Wallis for nonparametric
distributions were used as appropriate. We first com-
pleted an observed outcome analysis based on
observed outcomes for the women who completed
their 1-week postoperative incision check. We then
calculated an unadjusted relative risk and 95% CI for
the primary outcome. We then completed a second
outcome analysis for all women who were random-
ized and received their intended treatment despite
lack of follow-up at the 5- to 7- day incision check
by imputing missing data. We assumed that all
women who were lost to follow-up had developed
superficial surgical site infections. For the secondary
outcome of composite wound complication, we
assumed that complications that would not require
readmission happened (eg, seroma, hematoma, or
wound dehiscence) and we assumed that complica-
tions that would generally require inpatient readmis-
sion did not happen (eg, deep surgical site infections
or organ-space surgical site infections). Finally, we
conducted two subgroup analyses of women with
BMIs of 40 to 50 and BMIs of 50 or higher to see
whether these groups had differences in superficial
surgical site infections not observed in the larger
cohort.

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Table 3. Occurrence of Postoperative Complications

Intention-to-Treat Observed Assumed Superficial SSI if

Outcomes Lost to Follow-up
NPWT Dressing Standard Dressing Standard Dressing
Complication (n580) (n581) P (n586) P

Superficial SSI 12 (15) 8 (10) .35 13 (15) .98

Composite wound complication 25 (31) 24 (30) .87 29 (34) .73
Deep SSI 0 (0) 0 (0) — 0 (0) —
Organ SSI 1 (1) 4 (5) .37 4 (5) .37
Seroma 7 (9) 6 (7) .78 11 (13) .46
Hematoma 2 (3) 4 (5) .68 9 (11) .06
Wound dehiscence 14 (18) 13 (16) .84 13 (15) .83
Readmission 3 (4) 5 (6) .72 5 (6) .72
Reoperation 1 (1) 1 (1) 1.00 1 (1) 1.00
Antibiotic treatment
SSI (superficial, deep, organ- 14 (18) 10 (12) .39 17 (20) 1.00
space)
UTI 1 (1) 2 (3) 1.00 7 (8) .17
Pyelonephritis 0 (0.0) 0 (0) 5 (6) .06
Mastitis 0 (0) 0 (0) 5 (6) .06
Hospital length of stay (d) 3.2 (3–4) 3.2 (2–4) .51 3.2 (2–4) .51
Breastfeeding at discharge 52 (65) 63 (73) .31 63 (73) .31
SSI, surgical site infection; NPWT, negative pressure wound therapy; UTI, urinary tract infection.
Data are n (%) or median (interquartile range) unless otherwise specified.
Composite wound complication includes superficial SSI, deep SSI, organ-space SSI, seroma, hematoma, or wound dehiscence. If lost to
follow-up, women were assumed to have developed superficial SSI, seroma, and hematoma. Conditions that required hospitalization
(eg, deep SSI, organ-space SSI, and wound dehiscence) were assumed not to have occurred in women lost to follow-up.

At the time of study initiation (April 2015), based
on the current literature, we assumed an occurrence of
superficial surgical site infection of 20% of obese
women undergoing cesarean delivery.4,9,10 We deter-
mined that 400 women (200 prophylactic negative
pressure wound therapy, 200 standard dressing)
would need to be recruited to have an 80% power
to detect a 50% decrease in superficial surgical site
infection (assuming P,.05). We anticipated that
enrollment across the two sites would take 24 months.
At the completion of the anticipated 2 years of
recruitment, 166 women out of a planned 400 (42%)
had been enrolled in the study. This was likely the
result of the limitations of women’s ability to return
for device removal and incision evaluation 5–7 days
after delivery (many had been transported to the ter-
tiary recruiting site and lived a long distance from this
site). As a result of this low enrollment, the study’s
data safety monitoring board recommended an
unplanned interim analysis with futility calculation
to determine whether the study should continue.
We anticipated that to reach our original recruit-
ment goals, we would need to continue our study for
34 additional months. If we assumed that observed
outcomes in the remaining 244 women would
develop the primary outcome, superficial surgical site
infection, as predicted in the original sample size
calculation (20% superficial surgical site infection in
women with standard dressing and 10% in women
with prophylactic negative pressure wound therapy),
our study’s power to detect a difference between the
two interventions would be 29% at completion of
enrollment of our 400 participants. If we assumed that
the primary outcome in the remaining 244 women
would be the same as prevalence observed in the first
166 women who had already completed the study,
our study’s power to detect a difference between the
two interventions would be less than 0.1%. Therefore,
the determination of the data safety monitoring board
was that continued enrollment to original recruitment
targets was futile and the recommendation was made
to halt further enrollment and disseminate our
findings.
RESULTS
Women were recruited between January 5, 2015, and
January 7, 2017. A total of 166 women were random-
ized, 163 received their allocated treatment, and 161
(80 prophylactic negative pressure wound therapy and
81 standard dressing) returned for their postoperative
wound assessment approximately 1 week after cesar-
ean delivery (Fig. 1). The two randomization groups

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Table 4. Demographics and Clinical Characteristics of Women With Superficial Surgical Site Infection After
Cesarean Delivery (N5161)

Characteristic Superficial SSI (n520) No Superficial SSI (n5141) P

Group .32
Prophylactic negative pressure wound therapy 12 (60) 68 (48)
Standard dressing 8 (40) 73 (51)
Site .09
A 19 (95) 112 (79)
B 1 (5) 29 (21)
Maternal characteristics
Maternal age (y) 31.066 30.766 .85
Race .24
White 19 (95) 133 (99)
Black 1 (5) 0 (0)
Other 0 (0) 1 (1)
Ethnicity .23
Hispanic 1 (5) 1 (1)
Parity .66
1 9 (45) 43 (31)
2 6 (30) 53 (38)
3 4 (20) 36 (26)
4 or more 1 (5) 9 (6)
Gestational age (wk) .87
28 or less 0 (0) 4 (3)
Greater than 28–37 5 (28) 32 (25)
Greater than 37–42 13 (72) 93 (72)
Greater than 42 0 (0) 0 (0)
Gestational age (d) 261621 260624 .82
Prior cesarean deliveries .03
0 16 (80) 66 (47)
1 2 (10) 57 (40)
2 2 (10) 16 (11)
3 or more 0 (0) 2 (1)
BMI (kg/m2) 46.968 43.567 .06
BMI category (kg/m2) .02
35–40 3 (15) 58 (41)
Higher than 40 17 (85) 83 (59)
Preoperative serum hct (%) 34.866 30.2610 .04
Preoperative anemia (serum hct less than 36%) 9 (45) 101 (72) .02
Antenatal steroids 4 (20) 15 (11) .26
Diabetes mellitus .63
Type I diabetes mellitus 0 (0) 2 (2)
Type II diabetes mellitus 3 (16) 10 (8)
Gestation diabetes mellitus 3 (16) 27 (21)
Hypertension
Chronic hypertension 2 (10) 8 (6) .36
Gestational hypertension 1 (5) 8 (6) 1.00
Preeclampsia with severe features 2 (10) 13 (9) 1.00
Current smoker 3 (15) 23 (16) 1.00
Labor
Reason for admission labor and delivery .79
Spontaneous labor 12 (67) 83 (67)
Induction of labor 5 (28) 27 (22)
Scheduled cesarean delivery 1 (6) 14 (11)
Duration of rupture of membranes (min) 2726457 216 (425) .59
Duration of rupture of membranes (h) 1.00
Less than 18 18 (90) 127 (90)
18 or more 2 (10) 14 (10)
Chorioamnionitis present at the time of delivery 0 (0) 1 (1) 1.00
(continued )

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Table 4. Demographics and Clinical Characteristics of Women With Superficial Surgical Site Infection After
Cesarean Delivery (N5161) (continued )
Characteristic Superficial SSI (n520) No Superficial SSI (n5141) P

Intraoperative variables
Fetal weight (g) 3,19261,088 3,1796971 .96
1-min Apgar score 6.563 7.262 .15
5-min Apgar score 8.661 8.461 .61
Operative time (min) 86.3628 80.7624 .33
Type of anesthesia .10
Spinal–epidural 16 (80) 129 (92)
General 4 (20) 11 (8)
Skin incision .21
Pfannenstiel 19 (100) 100 (89)
Vertical midline 0 (0) 13 (12)
Skin closure 1.00
Subcuticular 18 (95) 103 (92)
Staples 1 (5) 9 (8)
Estimated blood loss (mL) 9556309 9496289 .93
Postpartum hemorrhage (greater than 1,000 mL) 9 (45) 65 (46) 1.00
Intraoperative blood transfusion 0 (0) 3 (2) 1.00
Concomitant procedures 1.00
Tubal ligation 6 (30) 42 (30)
Peripartum hysterectomy 0 (0) 0 (0)
SSI, surgical site infection; BMI, body mass index; hct, hematocrit.
Data are n (%) or mean6SD.

were similar in regard to maternal characteristics and
intrapartum and intraoperative events (Tables 1 and 2).
Twelve percent of women (20/161) completing
the 1-week incision check experienced superficial
surgical site infection. There were no statistically
significant differences in the occurrence of observed
superficial surgical site infections between women
using prophylactic negative pressure wound therapy
(12/80 [15%]) compared with women who received
the standard dressing (8/81 [10%], P5.35; Table 3;
relative risk 1.52, 95% CI 0.66–3.52). Assuming that
all women who were lost to follow-up developed
superficial surgical site infection, there still would
not have been a statistically significant difference in
the occurrence of superficial surgical site infection
between groups (12/80 [15%] vs 13/86 [15%], P5.98).
There were no significant differences in the occur-
rence of composite wound complications between
women using prophylactic negative pressure wound
therapy (25/80 [31%]) compared with women who
received the standard dressing (24/81 [30%], P5.87).
In a subgroup analysis of the 71 women with BMIs of
40 to 50, there were no statistically significant differences
observed in superficial surgical site infections in the
women using the prophylactic negative pressure wound
therapy (7/31 [23%]) compared with women receiving
standard dressings (7/40 [18%], P5.77). In a subgroup
analysis of the 34 women with BMIs higher than 50,
there were no differences in the occurrence of observed
superficial surgical site infections in women using the
prophylactic negative pressure wound therapy (21%
[4/19]) compared with women receiving standard dress-
ings (20% [3/15], P..99).
Risk factors for superficial surgical site infection
are explored in Table 4. In addition to maternal BMI
category, number of prior cesarean deliveries and pre-
operative anemia (serum hematocrit less than 36%)
were both associated with increased postcesarean
superficial surgical site infection (Table 4).
There were no statistically significant differences
observed for length of stay after delivery and breastfeed-
ing at the time of hospital discharge between women
with prophylactic negative pressure wound therapy and
standard dressings. Fifteen percent of women (12/80)
with the prophylactic negative pressure wound therapy
device had it removed early: five women for local skin
irritation, six women because the pump stopped work-
ing, and one additional woman requested early removal.
DISCUSSION
In this randomized controlled trial, we did not observe
a decrease in superficial surgical site infection after
cesarean delivery in obese women with the use of
prophylactic negative pressure wound therapy. Even in
a subgroup analysis of morbidly obese (BMI of 40 to 50)
and the most obese women (BMI higher than 50), who

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are considered to be at significantly higher risk of
surgical site infection and wound complication based
on published literature (Tran et al), we did not find
a difference in the occurrence of superficial surgical site
infection with the use of prophylactic negative pressure
wound therapy; however, the results of these subgroup
analyses are limited by small numbers.
Our study was limited by slow enrollment and
therefore failure to reach our planned sample size.
The two limiting factors in our enrollment were the
need to consent women before active labor to ensure
women could give informed consent free from pain
and the need for patients to return for an incision
check 5–7 days after their delivery. As a tertiary cen-
ter for a large rural geographic catchment area, many
women delivering at our facility could not feasibly
return for an incision check after discharge.
In conclusion, we did not observe a statistically
significant difference in postcesarean superficial surgical
site infection or composite wound complications
between women who used the prophylactic negative
pressure wound therapy and women who received
a standard dressing. There is currently a large multi-
centered National Institutes of Health-funded trial (Clin-
icalTrials.gov Identifier: NCT03009110) to examine the
use of prophylactic negative pressure wound therapy for
the reduction of wound complications in obese women
after cesarean delivery with a goal of 2,850 women.
Until the results of this or other trials are published,
10. Alanis MC, Villers MS, Law TL, Steadman EM, Robinson CJ.
we recommend against use of prophylactic negative
pressure wound therapy after cesarean delivery.
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