2013

http://informahealthcare.com/jmfISSN: 1476-7058 (print), 1476-4954 (electronic)

J Matern Fetal Neonatal Med, 2013; 26(8): 753–756! 2013 Informa UK Ltd. DOI: 10.3109/14767058.2012.755509

Cesarean skin closure preferences: a survey of obstetricians

A. Dhanya Mackeen, Tara Devaraj, and Jason K. Baxter

Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Jefferson Medical College of Thomas Jefferson University,

Philadelphia, PA, USA

Abstract

Objective: In light of the limited evidence directing cesarean skin closure techniques, weevaluated the factors guiding obstetricians’ preferences for closure method.Methods: From 07/11 to 12/11, an online survey was sent to obstetricians in ACOG Regions I andII. Obstetricians were asked to indicate their cesarean skin closure preferences whenconsidering various factors and to rank the importance of these factors in their decision.Practice type, experience and usual method of closure were also assessed.Results: Responses were received from 470 of 1400 surveyed (34% response rate), of which 422were analyzed. Similar proportions reported primarily using sutures (39%) or staples (48%); 13%use both methods equally. More obstetricians at community hospitals primarily use sutures(48% versus 39%, p50.001), while more at university hospitals primarily use staples (57% versus30%, p50.001). Listed in decreasing order of importance, sutures were preferred whenconsidering patient satisfaction, keloid susceptibility, cosmesis, first Pfannenstiel incisions orcost. Staples were preferred when considering wound infections, obese patients, chorioamnio-nitis, HIV/AIDS or busy labor floors (p50.001).Conclusion: The limited evidence to guide cesarean skin closure forces obstetricians to rely onpersonal experience. Our survey indicates that despite this limitation, obstetricians have specificpreferences for cesarean skin closure method.

Keywords

Cesarean closure techniques, staples, surgeonpreferences, surgical incision closure,sutures

History

Received 12 July 2012Revised 5 November 2012Accepted 30 November 2012Published online 11 January 2013

Introduction

In 2009, the cesarean delivery rate in the United States rose to

a record high of 33%, totaling more than 1.3 million cesarean

deliveries [1]. Although cesareans are one of the most

common surgical procedures performed in the United States,

there are many aspects of cesarean technique that are not well

studied, including closure of skin incisions [2].

The techniques used most often for incision closure are

staples and sutures [3]. Randomized controlled trials

comparing these two types of skin closure methods have

shown varying results with regard to pain, cosmesis and

wound morbidity [4–8]. Two recent meta-analyses high-

lighted that available trials on this topic were not powered to

assess significant differences in wound infection, nor did the

trials routinely control for possible confounding variables,

including BMI and administration of prophylactic antibiotics

prior to skin incision [9,10].

Therefore, given the conflicting available data, obstetri-

cians are forced to base their decisions for skin closure on

personal preference. This survey was designed to assess

obstetricians’ preferences for absorbable sutures or

nonabsorbable metal staples when considering different

factors related to patient history and outcomes.

Methods

This was an IRB approved study conducted via an online

survey from July to December 2011. The survey [11],

designed using Survey Monkey (Palo Alto, CA), was sent to

program coordinators of residency programs in Regions I and

II of the American Congress of Obstetricians and

Gynecologists in the United States. Region I includes New

York, Massachusetts, New Hampshire, Maine, Rhode Island,

Connecticut, Vermont; Region II includes Pennsylvania,

Ohio, Michigan, New Jersey, Indiana, Kentucky and

Delaware. Program coordinators then forwarded it to practi-

cing obstetrical residents and attendings at their institution.

The survey was also sent to members of the Obstetrical

Society of Philadelphia.

The survey was designed to assess two types of informa-

tion: demographics about the respondents and their prefer-

ences for skin closure methods. Demographics included

respondents’ experience level, practice type (university-

based or community-based) and state in which they practice.

Obstetricians indicated their preferences for skin closure

methods by choosing between absorbable sutures and

nonabsorbable metal staples, or by specifying whether other

Address for correspondence: A. Dhanya Mackeen, MD, MPH, 834Chestnut Street, Suite 400, Philadelphia, PA 19107, USA.Tel: 215.955.7996. Fax: 215.955.5041. E-mail: dhanya80@hotmail.com

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methods were preferred. If respondents stated that they use

absorbable sutures more than 60% of the time, sutures was

considered their primary method of closure. If respondents

stated that they use nonabsorbable metal staples more than

60% of the time, staples was considered their primary method.

If they used absorbable sutures and metal staples between

40% and 60% of the time, they were considered to use sutures

and staples with equal preference.

We assessed whether sutures or staples were preferred for

skin closure when considering a variety of factors. Patient

factors included presence of HIV/AIDS, history of wound

infection, keloid susceptibility, obesity, first Pfannenstiel

incision and repeat cesarean. Labor and delivery factors

included suspicion of chorioamnionitis, busy labor floor and

cost. Outcome factors included improvement of cosmetic

outcome. We then asked respondents to rate the importance of

each factor when choosing between staples and sutures. The

level of importance was assigned a score for analysis

purposes: very important was assigned a score of 2, somewhat

important was assigned a score of 1 and not important was

assigned a score of 0. Finally, obstetricians were asked to

estimate the percentage of cesareans in which skin closure

method was determined primarily by patient request.

Data was analyzed using the chi-square test for categorical

variables with a p value of less than 0.05 considered as

significant (SAS, version 9.2, Cary, NC). Clopper-Pearson

95% confidence intervals were reported for the binomial

proportion.

Results

Responses were received from 470 of 1400 surveyed (34%

response rate). After excluding surveys in which only

demographic information had been completed, 422 surveys

had information on closure preferences when considering the

various factors; 386 surveys had information regarding

preferences for closure and demographic information. Forty

percent of respondents practiced in Pennsylvania, Michigan,

Massachusetts and New York. Table 1 depicts the distribution

of respondents with respect to their experience level as well as

their practice type and their preferences for closure with

staples or sutures.

Of those surveyed, 4% (16/422) of obstetricians use

methods other than absorbable sutures and metal staples as

their primary method of closure; these included absorbable

staples and non-absorbable sutures. Of those remaining, 39%

of respondents primarily use absorbable sutures, 48%

primarily use metal staples and 13% use absorbable sutures

and metal staples with equal preference (Table 1). When

comparing subpopulations, there were no significant differ-

ences in skin closure preferences when comparing residents

and attendings. However, obstetricians at community hospi-

tals were significantly more likely to primarily use sutures

and practitioners at university hospitals were more likely to

use nonabsorbable staples (p50.001) (Table 1).

In decreasing order of importance, obstetricians were

significantly more likely to opt for sutures when taking into

account patient satisfaction, keloid susceptibility, improved

cosmetic outcome, first Pfannenstiel incision and cost

(Table 2 and Figure 1). Conversely, practitioners were

significantly more likely to choose to close with staples if

the patient was obese or had a history of wound infections, in

order to decrease the risk of wound infection, if chorioam-

nionitis was suspected, if the labor floor was busy or if the

patient had HIV/AIDS (Table 2 and Figure 1). When

considering repeat cesarean as a factor, there were no

significant differences in whether respondents chose to

close with staples or with sutures.

Almost 30% of respondents stated that patient preference

never dictates skin closure. An additional 53% stated that

patient preference determines closure in 1–10% of cesareans.

The remaining respondents felt that patient preference was a

factor in determining closure in 11–60% of cesareans.

Discussion

Even though the evidence is limited regarding superior

cesarean skin closure method, obstetricians have definite

preferences. It appears that regardless of patient or operative

factors, practitioners tended to have a strong preference for

staples or sutures, as only 13% of respondents noted that they

used these closure techniques equally. Other methods such as

absorbable staples and non-absorbable sutures are minimally

used as primary methods of closure (4%).

When comparing sub-populations, it was found that

obstetricians at community hospitals were more likely to

use sutures (48% versus 39%), while those at university

hospitals were significantly more likely to use metal staples

(57% versus 30%) (Table 1). Of note, 93% of the community

hospital based obstetricians surveyed had residency training

programs at their institution; thus, the preference for suture

use at community hospitals was not secondary to lack of

presence of residents in training.

Respondents chose absorbable sutures over metal staples

as the preferred method of skin closure when considering

patient satisfaction, improved cosmesis, first cesarean

Table 1. Distribution of respondents by experience level and practice type and their preferences for closure method.

n (%) Prefer sutures Prefer staples Use either p Value

Overall 386 (100) 152 (39) 183 (48) 51 (13) –

Distribution by experienceResidents 198 (51) 80 (40) 85 (43) 33 (17) 0.064Attendings 188 (49) 72 (38) 98 (52) 18 (10)

Distribution by practice typeCommunity hospitals 198 (51) 95 (48) 77 (39) 26 (13) 0.001University hospitals 188 (49) 57 (30) 106 (57) 25 (13)

754 A. D. Mackeen et al. J Matern Fetal Neonatal Med, 2013; 26(8): 753–756

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procedure, keloid susceptibility and cost. Patient satisfaction,

keloid susceptibility and cosmesis were considered of highest

importance in choosing suture for skin closure. This is

especially interesting, as current evidence shows no signifi-

cant difference in patient satisfaction [4,5,7,8]. Additionally,

four trials have included cosmesis as an outcome, with mixed

results. Three studies showed no difference between the two

closure methods [5,7,8] and one showed that sutures have a

better cosmetic outcome [6].

Respondents chose metal staples as the preferred method

for patients with a history of wound infection as well as in

patients in whom they were more concerned about wound

infection after cesarean. This coincides with respondents’

preferences for staple closure in women who are obese, have

HIV/AIDS, or have concurrent chorioamnionitis at time of

cesarean as these factors are known to be associated with

increased wound morbidity postoperatively. Staples were also

the method of choice when the labor floor was noted to be

busy, though we cannot be certain whether this is because

surgeons prefer the faster closure or whether there is pressure

from the labor floor to turn over cases faster; multiple studies

have shown that staples can be used to close the skin in less

time than sutures [4–6,8]. A history of wound infection,

decreasing the risk of wound infection, obesity and chor-

ioamnionitis were considered of highest importance in

choosing staples for skin closure. Of note, the available

literature has shown controversial results with respect to the

association between staples and wound morbidity [12].

Multiple studies have failed to show a significant difference

in wound complications between closure with staples and

suture [5–8], whereas one study showed that staples were

associated with increased wound complications [4].

To our knowledge, this is the first study that has assessed

the practice of cesarean skin closure techniques in the United

States. Although the survey was not administered on a

national scale, we were able to sample obstetricians practicing

in 14 different states. We have demonstrated that obstetricians

have particular preferences when choosing skin closure

methods after cesarean and that choice of closure varies

based on associated patient and operative factors.

Weaknesses of the study include the low response rate,

however, 470 practicing obstetricians did respond to the

survey. Additionally, the responses equally reflected resident

and attending physician preferences, as well as the prefer-

ences of those practicing in university- and community-based

hospitals. As the majority of respondents worked in programs

with residents (including the community-based programs), the

results of the survey are representative of obstetricians

practicing in hospitals with residency programs.

This survey demonstrates that obstetricians have specific

preferences for skin closure technique post cesarean. It will be

interesting to assess how providers’ preferences change as

more evidence becomes available.

Declaration of interest

The authors report no conflicts of interest. The authors alone

are responsible for the content and writing of the paper.

Table 2. Preferred closure method when certain factors are considered.

Absorbable sutures n, % (95% CI) Metal staples n, % (95% CI) p Value

Increased patient satisfaction; n¼ 408 358, 88 (84–91) 50, 12 (9–16) 50.001Improved cosmetic outcome; n¼ 389 307, 79 (75–83) 82, 21 (17–25) 50.001First Pfannenstiel incision; n¼ 396 289, 73 (69–78) 106, 27 (22–31) 50.001Keloid susceptibility; n¼ 396 266, 67 (63–72) 130, 33 (28–37) 50.001Cost; n¼ 381 239, 63 (58–68) 142, 37 (32–42) 50.001Repeat cesarean; n¼ 394 182, 46 (41–51) 212, 54 (49–59) 0.13History of wound infection; n¼ 408 98, 24 (20–28) 310, 76 (72–80) 50.001Obesity (BMI� 30 kg/m2); n¼ 410 118, 29 (23–34) 292, 71 (67–76) 50.001Busy labor floor; n¼ 401 122, 30 (26–35) 279, 70 (65–74) 50.001HIV/AIDS; n¼ 392 137, 35 (30–40) 255, 65 (60–70) 50.001Chorioamnionitis; n¼ 406 135, 33 (29–38) 271, 67 (62–71) 50.001Decreased wound infection; n¼ 394 163, 41 (36–46) 231, 59 (54–64) 50.001

BMI, body mass index; CI, confidence interval; HIV/AIDS, human immune-deficiency/acquired immunodeficiency syndrome.

Figure 1. Importance of individual factors when deciding which closure method to use.

DOI: 10.3109/14767058.2012.755509 Cesarean skin closure survey 755

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