title: The association of skin-incision type at cesarean with maternal and neonatal morbidity for women with multiple prior cesarean deliveries.
abstract: OBJECTIVE
  In women with multiple prior cesarean deliveries (CDs), vertical skin incisions are thought by some to result in better outcomes. The objective of this study was to compare maternal and neonatal outcomes according to the type of skin incisions among women with multiple prior CDs.
  
  
  METHODS
  This was a secondary analysis of MFMU Cesarean Registry data. Women undergoing repeat CD with a viable singleton gestation and history of ≥2 prior CDs were included in this analysis. Women who had indications for urgent CD (e.g., cord prolapse) or suspected placenta accreta were excluded. Maternal and neonatal outcomes of women with 2, 3 and ≥4 prior CDs were compared by skin-incision type (transverse vs. vertical) using univariable and multivariable analyses.
  
  
  RESULTS
  5007 women met the inclusion criteria. In univariable analysis, women with 2 prior CDs who had a vertical skin incision had shorter incision-to-delivery intervals (12.9 min vs. 14.1 min, p<0.001) but also higher rates of endometritis and composite adverse maternal outcomes (4.9% vs. 2.7%, p=0.001, 16.1% vs. 13.4%, p=0.026, respectively). Women with 3 prior CDs also had higher rates of composite adverse maternal outcomes (21.2% vs. 15.8%, p=0.042). In women with ≥4 prior CDs, prolonged hospitalization, composite adverse maternal outcomes, NICU admission and composite adverse neonatal outcomes also were higher with vertical skin incision (23.2% vs. 9.3%, p=0.005, 32.9% vs. 13.7%, p=0.001, 32.1% vs.19.6%, p=0.045, 32.9% vs.19.4%, p=0.024, respectively). In multivariable analyses, vertical skin incision remained associated with prolonged hospitalization and composite adverse maternal outcome among women with ≥4 prior CDs (aOR 3.40, CI 1.11-10.38, aOR=2.37, CI 1.02-5.55, respectively).
  
  
  CONCLUSIONS
  Vertical skin incision at the time of multiple repeat CD was not associated with better obstetric or perinatal outcomes and was associated among women with ≥4 prior CDs with a higher frequency of prolonged hospitalization and adverse maternal outcomes.
authors.affiliation: Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States. Electronic address: anna.palatnik@northwestern.edu.
authors.forename: Anna
authors.initials: A
authors.lastname: Palatnik
authors.affiliation: Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States.
authors.forename: William A
authors.initials: WA
authors.lastname: Grobman
mesh_terms: D000328:Adult; D017604:Cesarean Section, Repeat / Q000009:adverse effects* / Q000379:methods; D015331:Cohort Studies; D004716:Endometritis / Q000453:epidemiology / Q000209:etiology; D005260:Female; D006801:Humans; D007231:Infant, Newborn; D007232:Infant, Newborn, Diseases / Q000453:epidemiology / Q000209:etiology* / Q000628:therapy; D007363:Intensive Care Units, Neonatal; D007902:Length of Stay; D008297:Male; D054582:National Institute of Child Health and Human Development (U.S.); D061646:Operative Time; D011183:Postoperative Complications / Q000453:epidemiology / Q000517:prevention & control* / Q000628:therapy; D011247:Pregnancy; D016016:Proportional Hazards Models; D012042:Registries; D014481:United States / Q000453:epidemiology
keywords: Maternal morbidity; Multiple cesarean deliveries; Skin incision