Clinical practice
Wound management in obese
women following caesarean section
Abstract
The number of obese, childbearing women is growing and causing great
concerns in midwifery. Delivery via caesarean section entails the risk of
developing a wound infection, or wound dehiscence. While it is essential
to ensure that the care provided to women and their babies is safe,
effective, individualized and based on up-to-date evidence, this may not
always be the case and midwives may lack experience and appropriate
training in managing these wounds. In this article, the current evidence
on the impact of obesity on wound care management will be considered,
along with the advice midwives should give to women after a caesarean
section. The physiology of wound healing will be considered as well as
the need to assess the caesarean section incision correctly by examining
its appearance. Factors that affect wound healing in the obese woman
and how these impact on the wound care management and advice
offered by midwives will be discussed. Recommendations for midwifery
practice are made throughout and include suggestions on raising
awareness among staff on the impact that obesity has on wound care
management and advice through training.
T
he percentage of obese, childbearing
women has grown from between 3.29.9%
in 1990, to between 8.918.9% in 2004
(Kanagalingam et al, 2005; Usha Kiran et al, 2005;
Heslehurst et al, 2007a). The risks of obesity
are now frequently highlighted and it is impor-
tant for midwives to be aware of these risks. The
aim of this article is to draw attention to some of
the risks associated with obesity as it relates to
wound healing. A brief overview of the physiolog-
ical healing process and assessment methods will
be given, along with guidance to help midwives
make good quality decisions about wound care.
This article aims to help practitioners to consider
Stefania Nobbs the advice that is given to women after caesarean
Newly Qualified Midwife section to ensure good wound healing takes place.
Queen Elizabeth
Hospital NHS Trust, Obesity and risk
Kings Lynn, Norfolk Wound infections are a concern in todays NHS.
For new mothers this could result in delayed
Kenda Crozier wound healing, disruption of the wound, wound
Senior Lecturer dehiscence, pain and prolonged hospital stay. In
School of Nursing and very extreme circumstances it could lead to sepsis,
Midwifery, Faculty of organ failure and death (Santy, 2008). It is outside
Health, University of the midwifes remit to manage complicated wounds
East Anglia (Boyle, 2006) and the Nursing and Midwifery
Council (NMC) (2008) clearly states that a midwife
150
must refer to the most appropriate healthcare
professional in case deviation from the norm is
detected. However, it is part of the midwifes role to
be responsible for providing wound care service for
women who have had a caesarean section.
Anecdotal evidence suggests there is a lack
of understanding on the impact of obesity
on the caesarean section wound and a lack of
specific knowledge to provide good wound care
management and advice, particularly to obese
women. The body mass index (BMI), although
considered limiting as it does not take into consid-
eration body fat distribution (Ockenden, 2007)
or muscularity (National Institute for Health and
Clinical Excellence (NICE), 2006a; World Health
Organization, 2006), is the current method used
to classify obesity (Table 1). It is calculated by
dividing the weight in kg by the square of height
in metres (kg/height). In this article, the term
obese will refer to those with a BMI greater than
30 unless otherwise stated.
Among the risks associated with obesity
(Table 2), the last Confidential Enquiry into
Maternal and Child Health (CEMACH) report
2003-2005 showed that sepsis following infection
of the caesarean section incision killed five women,
all either overweight or obese (Lewis, 2007). The
link between wound infection following caesarean
section and obesity does not come as a surprise.
Many studies have classified obesity as the inde-
pendent risk factor for post-caesarean wound
infections (Myles et al, 2002; Schneid-Kofman et
al, 2005; Johnson et al, 2006).
Overall numbers of caesarean sections are
rising (NHS Information Centre, 2009) but there
is also evidence suggesting that obese women are
at greater risk of delivering via this method, either
electively or in an emergency (Sheiner et al, 2004;
Table 1. Categories of adult obesity
Body mass index Categorization
3034.99 Obese class I
3539.99 Obese class II
40 Obese class III
Source: World Health Organization (2006)
British Journal of Midwifery March 2011 Vol 19, No 3
 Clinical practice

Usha Kiran et al, 2005; Barau et al, 2006; Sherrard
et al, 2007; Denison et al, 2008).
Physiology of wound healing
Caesarean section incisions usually heal by
primary intention, which occurs when the skin
edges are brought together by sutures without
leaving any gap in the tissue (Vuolo, 2006).
Epithelialization can then take place within
2448 hours (Lloyd-Jones, 2007) and, for this
reason they are considered acute (Boyle, 2006).
On the other hand, if the wound has become
infected and part of the tissue has been destroyed,
the healing occurs by secondary intention (Boyle,
2006). In this case, the wound is left open to
allow for granulation and contraction to take
place (Dougherty and Lister, 2008). This type of
injury is categorized as chronic due to the fact
that the healing process is considerably slower
(Wilson and Clark, 2004). More rarely, an abdom-
inal surgical incision can be left to heal by tertiary
intention (Doughty and Sparks-Defriese, 2007), if
it is heavily contaminated or infected. The wound
is left open until cleaned and free of infection
before bringing the edges together and healing
the wound by primary intention.
Although the literature agrees as to the descrip-
tion of the normal physiological process of wound
healing (Dealey, 2005; Bale and Jones, 2006; Bates-
Jensen and Woolfolk, 2007), there are different ways
of naming the four phases involved (Table3). In this
article, the most common terminology will be used,
namely haemostasis, inflammation, proliferation
and maturation (Bale and Jones, 2006; Dougherty
and Lister, 2008). This division of the process into
phases is, however, a simplistic tool to explain the
complex series of events that occur within the
injured wound. In reality, each phase can overlap
and is affected by individual characteristics. It is
therefore difficult to give an exact time scale for the
occurrence of individual phases (Timmons, 2006).
Table 2. Risks related to obesity in pregnancy
Maternal morbidity Cardiac disease
Spontaneous first trimester and Pre-eclampsia
recurrent miscarriage Thromboembolism
Gestational diabetes Infection from other causes
Post-caesarean section wound infection Low breastfeeding rates
Postpartum haemorrhage
Source: Lewis (2007)
is used to convert fibrinogen to fibrin. This blood
protein joins the platelet plug to create a more
resistant clot (Doughty and Sparks-Defriese, 2007)
and reach haemostasis (Dealey, 2005).
Once the clotting factors are activated, vasodil-
atation occurs by the release of histamine and
prostaglandin from the breakdown of the clot
(Boyle, 2006). The blood vessels dilate and become
more permeable to ensure a good influx of fluid
(exudate) (Lloyd-Jones, 2007) to the wound which
contains antibodies, plasma proteins, leuko-
cytes and erythrocytes (Dealey, 2005). Redness
(erythema) and the inflammatory appearance is
due to the amount of blood flow in the capillaries,
while heat is caused by the large quantities of
warm circulating blood. Oedema is a consequen-
tial response to the permeability of the vessels and
pain may be due to, among other possibilities,
damaged nerve endings (Dealey, 2005), but this
should not be confused with infection.
Vasodilatation also ensures that white blood
cells (neutrophils) and macrophages are deliv-
ered to the site attracted by the clot (Boyle,
2006). Neutrophils arrive to the wound in the first
24hours (Boyle, 2006) to digest any foreign debris,
dead cells and bacteria by a process of phago-
cytosis. As their life span comes to an end while
performing this task, macrophages continue to
regulate the inflammatory response by the same
phagocytic action. Macrophages are producers of
growing factors that are essential for the smooth

The phases of wound healing Table 3. Various terminology in defining stages of wound
Haemostasis is the control of blood loss and the healing
formation of a momentary obstacle to possible
bacterial attacks (Doughty and Sparks-Defriese, Study Stage 1 Stage 2 Stage 3 Stage 4
2007). Immediately after the surgical incision Benbow Acute Destructive Proliferative Maturation
is made, blood vessels are disrupted and the (2005) inflammatory phase phase phase
sub-endothelial tissue is exposed. This attracts phase
platelets to the site of the injury which, by a Dealey Inflammation Reconstruction Epithelial- Maturation
process of aggregation, form a plug (Dealey, 2005). (2005) ization
Substances released by this chain of events cause
Bates- Inflammatory Epithelialization Proliferative Remodelling
vasoconstriction, which reduces bleeding (Boyle,
Jensen and phase phase phase
2006) and initiates the clotting cascade (Dougherty Woolfolk
and Lister, 2008). Clotting factors aid the conver- (2007)
sion of prothrombin into thrombin, which in turn

British Journal of Midwifery March 2011 Vol 19, No 3 151


Clinical practice
The weight of the abdomen can
cause poor circulation of blood to the
wound, thus causing ischaemia which
may increase risk of infection.
advancement of the healing process and the
achievement of angiogenesis, the creation of new
blood vessels (Bale and Jones, 2006). These supply
oxygen and key nutrients to the wound so that new
tissue can grow and develop.
It is in this proliferation phase that macro-
phages attract fibroblasts to produce a matrix of
collagen, a strengthening protein of the connec-
tive tissue (Boyle, 2006). Granulation tissues start
to form, usually within 3 days in acute wounds
(Dougherty and Lister, 2008). These new tissues
give the skin a pink and moist appearance with
red prominences (Hampton, 2004). At the same
time, epithelialization takes place as epithelial
cells are stimulated to multiply and disperse into
the wound surface by growth factors released
by macrophages (Dealey, 2005). This migration
stops when the cells come into contact with one
another, a process called contact inhibition (Bale
and Jones, 2006). Evidence shows that epitheliali-
zation occurs at a faster pace if the environment is
moist (Dealey, 2005; Timmons, 2006).
Maturation and remodelling of the wound
normally starts at around 21 days and can take up
to 1 year (Dougherty and Lister, 2008), although
timing varies depending on the individuals
circumstances (Boyle, 2006). Collagen fibres go
through a process of lysis and synthesis, becoming
more and more robust and able to rearrange
themselves at right angles to the wound edges
(Dealey, 2005). The reduction in vascular activity
also changes the newly-formed scar colour from
red to white (Benbow, 2005). The final outcome is
a scar tissue 80% as strong in comparison to the
original site (Boyle, 2006).
Factors complicating wound healing
in obese women
There are a number of factors which may inhibit
the normal progress of wound healing in obese
women, such as adipose tissue, poor mobility, poor
nutrition and comorbidities.
Adipose tissue
Anaya and Dellinger (2006) highlighted that
obesity makes the heart increase its cardiac output
and the stroke volume to provide for all tissues
in the body. However, the womans total blood
152
flow remains unchanged, possibly explaining why
adipose tissue is hypoperfused.
Baugh et al (2007) found that, beyond adipose
tissue being less vascularized, the accumulation of
fat on the neck and diaphragm impedes normal
breathing, thus causing reduced levels of oxygen
reaching the lungs and therefore the rest of the
body, including the wound. Wilson and Clark
(2004) found that the weight of the abdomen can
cause poor circulation of blood to the wound, thus
causing ischaemia which may put the healing
wound at greater risk of infection if paired with
tissue hypoxia. Although a state of hypoxia during
vasoconstriction allows for the healing process to
commence, oxygen has been shown to have a key
role in wound recovery.
A study by Troia (2002) suggested that main-
taining the obese womans oxygen saturation level
above 94% improves respiratory care. However,
Gallagher-Camden (2007) argued that maternal
vital signs need to be monitored closely, espe-
cially because their physical size can mask clinical
symptoms, as noted in the latest CEMACH report
(Lewis, 2007). Sitting at a 30o angle to reduce the
amount of adipose tissue pressing down on the
diaphragm may facilitate oxygen intake. This posi-
tion may cause an unwanted pressure injury in the
skin around the sacrum area if early mobilization
is not implemented.
Mobility
NICE (2005) recommends a risk assessment for
pressure ulcers for every obese patient within
the first 6 hours of admission, which should not
be used on its own but guided by clinical judg-
ment so that the patients unique overall wellbeing
is taken into consideration. One way to reduce
risk is to encourage the obese patient to mobi-
lize within 2 hours following surgery (Davidson
et al, 2003), while positional changes and consid-
eration on whether to limit sitting to less than
2 hours is advocated by NICE (2005). Mobility is
important in wound healing because it allows for
better blood circulation and better chest ventila-
tion (Nazarko, 2005). This is an area of concern for
obese womena study by Larsson and Mattsson
(2001) found that tasks of daily living such as
housework involving lifting and walking up and
down the stairs were perceived more challenging
by a sample of healthy obese women compared to
their non-obese counterparts.
Taking into consideration this evidence, the
problem becomes accentuated for obese women
post-caesarean section, as reported in Wilson and
Clarks (2004) review of morbidly obese patients
following an operation. The presence of the fresh
British Journal of Midwifery March 2011 Vol 19, No 3

abdominal wound made repositioning in bed diffi-
cultan extra element of care that the midwife
needs to be aware of when assisting this client
to move. The general advice advocated by NICE
(2004) and Baston (2005) to avoid lifting, twisting
and turning is therefore no longer sufficient.
However, moving and lifting a woman with a BMI
> 30 has been shown to be a challenge. Heslehurst
et al (2007b) found that a lack of trained midwives
and specialist bariatric equipment in the majority
of maternity units included in the analysis impeded
the extent to which women could be offered appro-
priate postnatal care.
Nevertheless, these potential obstacles cannot
be ignored. It is the duty of the midwife to
provide the best care for mothers and their
newborns (NMC, 2004). Mobility is also impor-
tant for this client group because it diminishes
other risks strongly linked to obesity such as
thromboembolism (Alexander and Liston, 2006),
pressure sores (Baugh et al, 2007) and wound
dehiscence (Ramsey et al, 2005; Robinson et al,
2005). To achieve a positive outcome, Gallagher
(2005) proposed the formulation of a pre-
planning protocol headed by a bariatric team,
which can include key healthcare professionals
from different disciplines with an interest or a
speciality in this condition (such as obstetri-
cians, midwives, physiotherapists, tissue viability
nurses, haematologists and dietitians). Such a
protocol fits into NICE (2003) guidance that
only midwives specifically trained in moving this
patient group and handling specially-designed
equipment for this purpose should undertake
such tasks, to ensure safety for patients and staff.
Poor nutrition
Nutritional deficiency is another factor to consider
when analysing wound healing in obese women
(Gallagher-Camden, 2007). A very limited number
of studies have examined both nutritional defi-
ciency and obesity, and of these, most studies
relied on self-reporting questionnaires to collect
data, with inherent limitations. Derbyshire et al
(2006) analysed food intake in women during
their first trimester of pregnancy and corre-
lated it to their BMI. The results demonstrated
that women with high BMIs were more likely to
report lower dietary energy, fibre, iron and folate
intake than their opposites. Similar results were
reported in an American study (Laraia et al, 2007),
which examined the self-reported dietary intake
questionnaires of 2394 women between 26 and
28weeks gestation.
Furthermore, evidence has suggested that in
an obese woman, fast depletion of lean body
British Journal of Midwifery March 2011 Vol 19, No 3
Clinical practice
The accumulation of fat on the neck and diaphragm impedes normal breathing, thus
causing reduced levels of oxygen reaching the lungs and therefore the rest of the body,
including the wound.
tissue (a catabolic state) while maintaining body
fat (Collins, 2003; Baugh et al, 2007) to produce
necessary energy for the task required, may put her
body into negative nitrogen balance and wound
healing may be further compromised (Wilson
and Clark, 2004). Taking into consideration the
findings from these studies, the likelihood of an
obese woman experiencing a delay in the normal
repairing process of a caesarean section wound is
high. Reduced intake of energy-rich food such as
carbohydrates translates to other sources of energy
being used, such as proteins (Gray and Cooper,
2001). However, proteins are required in greater
quantities during most of the stages of wound
healing: for angiogenesis occurring in the inflam-
matory phase; for fibroblasts, endothelial cells and
collagen synthesis in proliferation; and lastly for
remodelling (Boyle, 2006). Folate and iron defi-
ciencies can affect the immune system, as well
as new tissue formation and the levels of oxygen
present in the blood (Boyle, 2006).
Comorbidities
The most common comorbidity affecting obese
pregnant women is diabetes. In fact, in the general
population, the NHS Information Centre (2010)
reported that an obese woman is 13 times more
likely to develop type 2 diabetes than a non-
obese woman. Peppa et al (2009) found that
when diabetes is present, the inflammation phase
becomes disorganized, thus causing a delay in
the wound healing chain of events. In the next
phase, the number of growth factors produced by
macrophages is reduced, which limits the mobility
153
Clinical practice
of the fibroblasts required to produce collagen.
Finally, the wound may find it difficult to contract
and remodel because myofibroblast occurrence is
retarded and the cells that managed to survive are
stretched to their functional limits. In addition
to this, a new study by Lioupis (2005) has found
that advanced glycation end products (AGEs)
produced by hyperglycaemiaare linked to the
dysfunction of endothelial cells and extravascular
matrix, blood vessel permeability and stiffness
of the vessels walls, thus causing the blockage of
blood flow. Therefore, underlying management of
the diabetes is essential not only throughout preg-
nancy but afterwards to ensure optimum healing.
Surgical technique and dressings
Evidence suggests that while it is important to
know that the incision to the uterus can be of two
kinds (the lower segment and the classical inci-
sion) (Ndala, 2005), it is the surgical technique
used to incise the abdominal skin that has rele-
vance to subsequent wound care (Houston and
Raynor, 2000; Wall et al, 2003; Alexander and
Liston, 2006; Hofmeyr et al, 2008).
Wall et al (2003) looked at the rate of wound
complications in women with a BMI >40 after
vertical incision of the abdominal wall (also
known as the midline incision). Contrary to their
formulated hypothesis that the vertical incision
gives obese women a lower number of wound
complications, including infection, compared to
the transverse incision, they found that this type of
technique had the opposite result. Of the women
undergoing a vertical incision, 34.6% had a wound
complication compared to 9% of those with a
transverse incision, a difference that remained
evident when only wound infections were taken
into consideration (19% against 7%). However, the
authors inability to establish the exact technique
used by the surgeons does hinder the strength
of the results. They recognize that a randomized
controlled trial needs to be undertaken in order to
gain greater insight.
Guidelines on caesarean sections from NICE
(2004) recommend the best technique as being
the Joel-Cohen methoda transverse cut through
the skin layer only, located higher than the
Pfannenstiel (Hofmeyr et al, 2008). However, having
studied the evidence used to formulate their recom-
mendations, it appears that the distinction between
obese and non-obese women has not been recog-
nized and therefore the relevance of the guidance
to consideration of obese women is debateable.
The modern theory of moist wound healing
considers favourable an environment which, as the
name implies, is moist and also warm (Sussman,
154
2007). However, in order to facilitate good wound
recovery in a transverse incision, it is important
that the presence of excessive moisture is avoided
and the dressing changed if wet or soiled (Wilson
and Clark, 2004). Marchant (2009) suggested
advising these women to place a non-adhesive
dressing over the sutured incision.
Additionally, if obese women have undergone a
low transverse abdominal incision to deliver their
newborn, they may have difficulties in accessing
the wound during cleaning and self-assessing
it to successfully pick up on any early signs of
infection. Having their partner included in the
wound care plan and during information sharing
may provide women with the beneficial added
support they need in hospital and at home. Risk
awareness information and education needs to
be carried out in a sensitive manner, taking into
consideration not only womens health condi-
tion but also their social and psychological needs
(Department of Health, 2007).
In a personal account of her time in hospital
while obese, Spratt (2007) reported feeling more
comfortable with her husband because he knew
her and her routine. NICE (2006b) advocates
including partners in womens care as they can offer
valuable support, both practical and psychological.
Despite this, their involvement may not always
be what women want. Some obese women in
Nyman et als (2010) study recounted feeling
uncomfortable exposing their body to their part-
ners following delivery and were ashamed of
their body size and unhappy with the way they
looked. By listening to individual women and
understanding their needs, the midwife can better
identify and implement the most suitable care
plan to avoid the occurrence of such feelings.
While not evidence-based, it could be argued that
obese women would benefit from more frequent
visits from the community midwife, although this
could be difficult in an already stretched postnatal
care service.
Recommendations for practice
The literature illustrates that further training and
evidence-based guidance is needed to ensure that
midwives have a greater understanding of the risks
of wound infection associated with obesity, the
normal physiological process of wound healing
and how obesity can impact on healing. To this
end, it makes sense for maternity units to under-
take surveys into current knowledge levels of staff,
and where possible to provide training for staff on
wound care on a regular basis and on how obesity
may impact on current wound care management
and advice for women post-caesarean section.
British Journal of Midwifery March 2011 Vol 19, No 3

The creation of a wound assessment form, if not
currently available, can help midwives in moni-
toring obese women from recovery through to
the last postnatal visit carried out by the commu-
nity midwife at home, if necessary. By expanding
midwives knowledge of dietary requirements
including nutritional supplements specific to
obese women in the postnatal period, the risk of
wound infection can be reduced.
Conclusions
Literature relating to wound management
following caesarean section is scarce, of mixed
quality and partly based on the general popula-
tion. However, it is clear that in the near future,
the midwife may be caring for more women with
high BMI, and therefore there is a greater need
for obesity-specific wound care management and
advice. It is apparent that there are several factors
in obesity that can alter the normal physiological
healing process of a caesarean section wound and
increase the womans chances of developing an
infection if steps are not taken to minimize this
risk. It has been noted that rigorous monitoring of
obese womens vital signs may be required as their
condition can mask clinical signs (Lewis, 2007).
It is important that midwives trained in moving
and lifting this client group facilitate early mobi-
lization both in and out of bed, with or without
the use of specially-designed bariatric equip-
ment (NICE, 2003). Risk awareness information
and education on wound assessment needs to be
given sensitively, taking into consideration indi-
vidual health conditions, as well as social and
psychological needs. BJM
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Key points
ll Growing evidence shows that the percentage of obese, childbearing
women is increasing and that standard wound care management is no
longer sufficient to meet their specific needs
ll Further training and evidence-based guidance in wound healing and
wound care management for obese women is a current pressing need
ll A survey of staff knowledge may be beneficial in identifying the training
requirements to target within the maternity unit
ll The use of wound assessment forms throughout the whole postnatal
phase could ensure closer monitoring
ll Risk awareness information and education need to be offered by
midwives in a sensitive manner and take into consideration the
womens health, social and psychological requirements
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British Journal of Midwifery March 2011 Vol 19, No 3
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