\documentclass[10pt]{article}

\usepackage{fullpage}
\usepackage{setspace}
\usepackage{parskip}
\usepackage{titlesec}
\usepackage[section]{placeins}
\usepackage{xcolor}
\usepackage{breakcites}
\usepackage{lineno}
\usepackage{hyphenat}





\PassOptionsToPackage{hyphens}{url}
\usepackage[colorlinks = true,
            linkcolor = blue,
            urlcolor  = blue,
            citecolor = blue,
            anchorcolor = blue]{hyperref}
\usepackage{etoolbox}
\makeatletter
\patchcmd\@combinedblfloats{\box\@outputbox}{\unvbox\@outputbox}{}{%
  \errmessage{\noexpand\@combinedblfloats could not be patched}%
}%
\makeatother


\usepackage{natbib}




\renewenvironment{abstract}
  {{\bfseries\noindent{\abstractname}\par\nobreak}\footnotesize}
  {\bigskip}

\titlespacing{\section}{0pt}{*3}{*1}
\titlespacing{\subsection}{0pt}{*2}{*0.5}
\titlespacing{\subsubsection}{0pt}{*1.5}{0pt}


\usepackage{authblk}


\usepackage{graphicx}
\usepackage[space]{grffile}
\usepackage{latexsym}
\usepackage{textcomp}
\usepackage{longtable}
\usepackage{tabulary}
\usepackage{booktabs,array,multirow}
\usepackage{amsfonts,amsmath,amssymb}
\providecommand\citet{\cite}
\providecommand\citep{\cite}
\providecommand\citealt{\cite}
% You can conditionalize code for latexml or normal latex using this.
\newif\iflatexml\latexmlfalse
\providecommand{\tightlist}{\setlength{\itemsep}{0pt}\setlength{\parskip}{0pt}}%

\AtBeginDocument{\DeclareGraphicsExtensions{.pdf,.PDF,.eps,.EPS,.png,.PNG,.tif,.TIF,.jpg,.JPG,.jpeg,.JPEG}}

\usepackage[utf8]{inputenc}
\usepackage[ngerman,greek,english]{babel}



\usepackage{float}








\begin{document}

\title{Subcutaneous tissue closure technique during cesarean delivery: Don't
interrupt, better continue}



\author[1]{Roy Lauterbach}%
\author[1]{Chen Ben David}%
\author[1]{Gal Bachar}%
\author[1]{Naftali Justman}%
\author[1]{Emad Matanes}%
\author[2]{Yuval Ginsberg}%
\author[1]{Dana Vitner}%
\author[2]{Ron  Beloosesky}%
\author[2]{Zeev Weiner}%
\author[1]{Yaniv Zipori}%
\affil[1]{Rambam Health Care Campus}%
\affil[2]{Affiliation not available}%


\vspace{-1em}



  
  \date{June 16, 2024}


\begingroup
\let\center\flushleft
\let\endcenter\endflushleft
\maketitle
\endgroup





\selectlanguage{english}
\begin{abstract}
Objectives: To determine the rates of surgical site infections following
continuous as compared to interrupted subcutaneous tissue closure
technique during cesarean delivery. Design: Retrospective study.
Setting: Tertiary, university-affiliated medical center. Population:
Term pregnant women who underwent elective or emergent cesarean delivery
at our center during the years 2008-2018. Methods: Group allocation was
based on type of subcutaneous tissue closure. The study group included
women who underwent either elective or emergent cesarean delivery with
continuous subcutaneous tissue closure, while the control group
comprised those with interrupted subcutaneous tissue closure. We
excluded women with suspected infectious morbidity prior to cesarean
delivery. Main outcome measures: Rate of surgical site infection (SSI)
comparing women who had undergone continuous as compared to interrupted
subcutaneous suturing. Results: Final analysis included 6,281 women. We
performed continuous subcutaneous tissue closure in 37.4\%
(1,867/4,988) of scheduled cesarean deliveries, and 45.8\% (592/1,293)
of emergent cesarean deliveries. The rate of SSI was significantly
lower following continuous as compared to interrupted subcutaneous
tissue closure, in both elective (2.7\% vs. 4.5\%, respectively,
P=0.031) and emergent cesarean delivery (3.2\% vs. 5.4\%,
respectively, P=0.036), in nulliparous and multiparous women. Similarly,
secondary outcomes such as re-admission rates within 6 weeks due to SSI,
post-operative maternal fever, and need for antibiotic treatment were
significantly lower following continuous subcutaneous closure technique.
Conclusions: Continuous subcutaneous closure technique during cesarean
delivery yields a lower rate of surgical site infections compared to the
interrupted technique.%
\end{abstract}%



\sloppy


\textbf{Subcutaneous tissue closure technique during cesarean delivery:
Don't interrupt, better continue }

Roy Lauterbach, MD \textsuperscript{1}; Chen Ben David,
MD\textsuperscript{1}; Gal Bachar, MD \textsuperscript{1}; Naphtali
Justman, MD \textsuperscript{1}; Emad Matanes, MD \textsuperscript{1};
Yuval Ginsberg, MD \textsuperscript{1}; Dana Vitner,
MD\textsuperscript{1}; Ron Beloosesky, MD\textsuperscript{1, 2}; Zeev
Weiner, MD \textsuperscript{1, 2}; Yaniv Zipori, MD\textsuperscript{1}

\textsuperscript{1} Department of Obstetrics and Gynecology, Rambam
Health Care Campus, Haifa, Israel

\textsuperscript{2} Ruth \& Bruce Rappaport Faculty of Medicine -
Technion Institute of Technology, Haifa, Israel

\textbf{Corresponding author:} Chen Ben David, M.D., Department of
Obstetrics and Gynecology, Rambam Health Care Campus, Haifa 3109601,
Israel. Tel: 972-4-7771779. Fax: 972-4-7771778.

e-mail: chenbd0412@gmail.com

\textbf{Running Head:} Subcutaneous tissue closure technique during
cesarean delivery

\textbf{Abstract}

\textbf{Objectives:} To determine the rates of surgical site infections
following continuous as compared to interrupted subcutaneous tissue
closure technique during cesarean delivery.

\textbf{Design:} Retrospective study.

\textbf{Setting:} Tertiary, university-affiliated medical center.

\textbf{Population:} Term pregnant women who underwent elective or
emergent cesarean delivery at our center during the years 2008-2018.

\textbf{Methods:} Group allocation was based on type of subcutaneous
tissue closure. The study group included women who underwent either
elective or emergent cesarean delivery with continuous subcutaneous
tissue closure, while the control group comprised those with interrupted
subcutaneous tissue closure. We excluded women with suspected infectious
morbidity prior to cesarean delivery.

\textbf{Main outcome measures:} Rate of surgical site infection (SSI)
comparing women who had undergone continuous as compared to interrupted
subcutanous suturing.

\textbf{Results:} Final analysis included 6,281 women. We performed
continuous subcutaneous tissue closure in 37.4\% (1,867/4,988) of
scheduled cesarean deliveries, and 45.8\% (592/1,293) of emergent
cesarean deliveries. The rate of SSI was significantly lower following
continuous as compared to interrupted subcutaneous tissue closure, in
both elective (2.7\% vs. 4.5\%, respectively, P=0.031) and emergent
cesarean delivery (3.2\% vs. 5.4\%, respectively, P=0.036), in
nulliparous and multiparous women. Similarly, secondary outcomes such as
re-admission rates within 6 weeks due to SSI, post-operative maternal
fever, and need for antibiotic treatment were significantly lower
following continuous subcutaneous closure technique.

\textbf{Conclusions:} Continuous subcutaneous closure technique during
cesarean delivery yields a lower rate of surgical site infections
compared to the interrupted technique.

\textbf{Key words:} Cesarean delivery (CD), subcutanous suturing,
surgical site infection (SSI).

\textbf{Introduction}

Cesarean delivery (CD) rates continues to rise worldwide
.\textsuperscript{1--3}, accounting for more than 26\% of births in the
United Kingdom in 2015 . Although considered safe, CD is still
associated with both short- and long-term maternal
morbidities.\textsuperscript{4}

Postpartum surgical site complications such as hematomas, seromas,
surgical site infection (SSI), and wound breakdown develop in 1\% - 2\%
of both scheduled and emergency primary CDs.\textsuperscript{6--8} Risk
factors for wound complications include high body mass index (BMI) and
comorbidities.\textsuperscript{9} One of the preventive measures for
reducing the incidence of wound complications following CD is
approximation of the subcutaneous tissue.\textsuperscript{10} A 2004
Cochrane review addressed this surgical step and demonstrated a
significant one-third reduction in all surgical site complications
following suturing of the subcutaneous layer.\textsuperscript{11} A
later meta-analysis further supported a reduction in the odds of
developing any type of wound complication following this intervention,
particularly in women with obesity and subcutaneous tissue depth [?] 2
cm.\textsuperscript{12}

Despite the above evidence of subcutaneous tissue closure superiority,
the preferred surgical technique for subcutaneous tissue closure has not
been adequately studied. A single randomized controlled trial, comparing
continuous to interrupted suturing in women with a BMI \textgreater{} 30
kg/m\textsuperscript{2}, showed lower rates of all wound complications
when using interrupted suturing.\textsuperscript{13} However, it appears
that results of this study were insufficient to make a clear decision
about subcutaneous tissue closure technique. In recent years, specific
guidelines addressing each of the pre, intra, and post-CD steps have
been developed in an attempt to improve patient
outcome.\textsuperscript{14-18} These guidelines, which include the
Enhanced Recovery After Surgery (ERAS) program, also did not provide a
clear statement about the preferred suturing technique for subcutaneous
approximation following CD.

Therefore, the current study aimed to report the rate of SSI when
comparing two surgical techniques, continuous versus interrupted, of
subcutaneous tissue closure during CD.

\textbf{Materials and Methods}

\textbf{Study procedures}

This was a retrospective study of women delivered by CD at our tertiary
care center, during 2008-2018. Our Obstetrics and Gynecology department
provides care to approximately 15,000 patients annually, including
nearly 5,500 births. The study was approved by our local Research
Ethics Board (0361-19-RMB). Informed consent was waived for acquisition
of de-identified patient data. Patient information was accessed through
the hospital's computerized database, including patients' demographics
and general medical and obstetric characteristics, in addition to both
intrapartum and postpartum maternal and neonatal variables. Furthermore,
known associated factors and morbidities relevant to surgical site
complications were also identified, such as BMI, total time duration of
the CD, diabetes of pregnancy, and number of prior CDs. The data were
used for multivariable regression analysis.

The study group was comprised of women with known pregnancy outcomes at
or beyond 37 weeks' gestation who underwent either elective or emergent
CD with continuous subcutaneous tissue closure (c-STC), while the
control group was comprised of those with interrupted subcutaneous
tissue closure (i-STC). Gestational age was confirmed by first trimester
ultrasound. Exclusion criteria included patients who received any
antibiotic regimen other than the routine prophylactic cephalosporin (or
clindamycin in cases of drug allergy) before the CD or GBS prophylaxis.
We follow the risk factor-based approach and provide intrapartum
chemoprophylaxis to prevent early-onset GBS neonatal disease after [?] 18
hours of prolonged rupture of membranes. Wide spectrum intravenous
antibiotics are also prescribed to women with suspected intrapartum
clinical chorioamnionitis, defined as isolated maternal fever with one
or more of the following: maternal tachycardia, fetal tachycardia,
leukocytosis, uterine tenderness, and malodorous amniotic fluid, or
patients with postpartum endometritis. In addition, we excluded women
who underwent CD due to multiple gestation, as these have been shown in
a previous studies to have increased rates of SSI.\textsuperscript{19}

Our institutional general CD technique is in alignment with the ERAS
guideline\textsuperscript{15} and consists of the following steps: 

\begin{enumerate}
\tightlist
\item
  Regional anesthesia is the principal method of anesthesia.
\item
  Prophylactic intravenous cephalosporin 2 g, or intravenous
  clindamycin 900 mg in case of penicillin allergy, is given within 60
  minutes of skin incision.
\item
  The CD surgical site is prepared with chlorhexidine-alcohol scrub.
\item
  The vagina is scrubbed with 4\% chlorhexidine.
\item
  A Pfannenstiel skin incision is performed.
\item
  Exposure of the subcutaneous tissue layer, opening of the underlying
  fascia, bluntly or sharply, is done while maintaining hemostasis, and
  creating a bladder flap. This is followed by low uterine segment
  transverse incision and delivery of the newborn.
\item
  The choice between a single or double layer for hysterotomy site
  closure is at the primary surgeons' discretion.
\item
  The peritoneum is not routinely approximated.
\item
  We close the fascia layer with continuous sutures.
\item
  Since we cannot measure reliably the subcutaneous tissue layer
  thickness, it is our department routine to suture this layer with 2-0
  Vicryl (Ethicon). The choice between c-STC or i-STC is at the primary
  surgeon's discretion. c-STC sutures were placed approximately 1 cm
  from the edge of the incision and 1 cm apart, without excessive
  tension.
\item
  At the time of the study, the skin was closed with metal clips,
  covered with sterilized dressing, and kept dry for approximately 24
  hours. 
\item
  Unless complications arise, women are hospitalized for 96 hours,
  during which evaluation and care of the surgical wound site is made.
\item
  Metal clips are removed in community health care facilities, usually
  within 5-7 days postoperatively.
\end{enumerate}

The primary outcome of the study was the rate of postpartum SSI, defined
as localized abdominal/wound tenderness with or without maternal body
temperature \textgreater{} 38\selectlanguage{ngerman}°C, and at least one of the following:
purulent drainage from the superficial incision, culture positive, or
incision opened by the surgeon. Secondary outcomes included the rate of
re-admission within 6 weeks postpartum due to SSI, rate and duration of
maternal fever and antibiotic use, CD-to-SSI time interval, rate of
bacteremia/sepsis, and post-op duration of hospitalization.

\textbf{Statistical analysis}

Descriptive variables were reported as means (±SD) for continuous
variables and numbers (percentages) for categorical variables. Study
variables were compared based on the student t-test, \selectlanguage{greek}χ\selectlanguage{english}2 test, and ANOVA.
A multivariable regression model was used while controlling for
significant univariate factors found to be associated with a positive or
a negative outcome for surgical site infection including maternal age,
BMI, gestational diabetes and duration of CD. A 95\% confidence interval
was considered statistically significant. SPSS for Windows, version 26
(SPSS, Inc., Chicago, IL), was used for data management and statistical
analysis. Separate sub-analyses were performed for both the elective and
emergent surgery groups.

\textbf{Results}

Maternal demographic characteristics, depicted in Table 1, were
comparable between the groups. Figure 1 presents a flow chart of
patients whose subcutaneous tissue layer was closed with either c-STC or
i-STC, and provides the primary outcome of the study. During the 10-year
study period, 12,896 pregnant women underwent CDs (incidence 23.4\%),
of whom 6,281 women were eligible for the final analysis. We performed
c-STC in 37.4\% (1,867/4,988) of the scheduled CDs, and in 45.8\%
(592/1,293) of the emergent CDs. The rate of SSI was significantly lower
following c-STC compared with i-STC, in both elective (2.7\% vs. 4.5\%,
P\textless{}0.0001) and emergent (3.2\% vs. 5.4\%, P=0.031) CDs.

Secondary outcomes are presented separately for elective and emergent
CDs in Tables 2 and 3, respectively. Among the scheduled CDs, we
observed that rates of readmission (0.9\% vs. 1.7\%, P=0.0025),
post-operative maternal fever (3.2\% vs. 5.3\%, p=0.021), and need for
antibiotic treatment (2.7\% vs. 4.3\%, P=0.038) were significantly lower
in the c-STC group as compared to the i-STC group. Similar findings were
observed for emergent CDs. No differences were found in the mean
duration of maternal fever, mean duration of antibiotic treatment,
CD-to-SSI latency interval, rates of bacteremia and/or sepsis, or
duration of hospitalization.

In a separate parity-based sub-analysis, significant findings were in
favor of the c-STC group as well. The rate of SSI in nulliparous women
was significantly reduced following c-STC as compared to i-STC in
elective (2.4\% vs. 4.2\%, P=0.029) and emergent (3.1\% vs. 5.6\%,
P=0.033) CDs. A lower rate of SSI was also noted among multiparous women
after c-STC as compared to i-STC, in both elective (2.8\% vs.
4\%,P=0.045) and emergent (3.7\% vs. 6.5\%, P=0.034) CDs. Re-admission
rates due to SSI were also significantly lower in nulliparous and
multiparous women following c-STC as compared to i-STC both in
elective (0.9\% vs. 1.7\%, P=0.0025) and emergent (1.5\% vs. 3.1\%,
P\textless{}0.0001) CDs.

\textbf{Discussion} 

\textbf{Main Finding}

The present study implies superiority of c-STC as compared with i-STC
approximation technique during CD, with significantly lower rates of
SSI, maternal fever, need for antibiotic use, and readmission at weeks
postpartum 6. These findings are consistent in both elective and
emergent CDs, among both nulliparous and multiparous women.

The overall incidence of postpartum surgical site complications has been
reported as 1\% - 18\%.\textsuperscript{6,7,20} These complications
disrupt recovery, increase the use of antibiotics and analgesics, and
prolong hospitalization.\textsuperscript{21} In particular, women with
post-operative SSI are less likely to breastfeed and more likely to
experience postpartum depression, thus negatively affecting both mothers
and their neonates.\textsuperscript{22}

\textbf{Strengths and Limitations}

Thus far, the current study is the largest to compare two surgical
techniques for subcutaneous tissue closure during CD, sufficiently
large to assess infrequent outcomes between the study groups. The
retrospective nature of the study in nature carries some limitations. We
were unable to analyze other wound complications such as hematomas,
seromas, wound breakdown, and culture results, as these were not
adequately reported in the outpatient follow-up of these women. In
addition, since in many centers skin closure by sutures or dissolvable
staples is the standard of care today, these results may not be
generalizable for those practices though the surgical technique still
shows a significant decrease in SSI based on a single change in CD
steps.

\textbf{Interpertation}

As previously mentioned, subcutaneous tissue approximation during CD has
been demonstrated to reduce post-operative wound
complications.\textsuperscript{23} In a randomized controlled trial of
116 women following CD by Husslein et al. (2014), subcutaneous tissue
closure was associated with lower rates of post-operative hematomas as
compared to the non-closure group (4\% vs. 25\%,
p\textless{}0.005).\textsuperscript{24} A 2017 meta-analysis of ten
studies (n=3,696) by Pergialiotis et al. (2017), which evaluated the
rates of wound complications between closure and non-closure of the
subcutaneous layer during CD, reported a significant reduction in all
wound complications in favor of the closure technique group (odds ratio
0.66, 95\% CI 0.47--0.93).\textsuperscript{12} Other studies found
subcutaneous tissue approximation to be more efficient with increased
subcutaneous thickness.\textsuperscript{11,25} Following these results,
current guidelines recommend suturing the subcutaneous tissue if the
thickness measured is 2 cm and
above.\textsuperscript{14,15}Nevertheless, there is a limited data
regarding the preferred surgical technique.

In a randomized trial, Alalfy et al. (2019) compared 198 women assigned
for continuous subcutaneous suturing and 199 women assigned for
interrupted sutures.\textsuperscript{12} The results indicated
significantly higher complications rates in the continuous suturing
group as compared with interrupted suturing group. Rates of wound
infection in their study reached 8.6\% in the continuous suturing group
as compared with only 1.5\% in the interrupted suturing group (odds
ratio 6.1, CI 1.8--21.3, p=0.001). However, one should notice that in
contrast with our study, women with previous CD or medical histories,
such as gestational diabetes mellitus, hypertension disorders, or a BMI
above 30kg/m\textsuperscript{2} were excluded. In addition, the
methodology of that study has been criticized, as critical information
such as sample size calculation, methods of randomization, and reports
on the decision of variables used for regression analysis were
lacking.\textsuperscript{26} In contrast, we demonstrated a significant
advantage for continuous subcutaneous suturing, and although
retrospective, included a large heterogeneous group of 6,281 patients
who may better represent common daily practice. Our cohort, that nearly
reached the pooled number of patients evaluated in the meta-analysis
performed by Pergialiotis et al.,\textsuperscript{12} enabled us to
describe and compare outcomes between subgroups of elective and emergent
CD.

\textbf{Conclusion}

Our study demonstrated significantly lower rates of post-CD SSI
following continuous subcutaneous sutures as compared to interrupted
subcutaneous sutures. We believe that performing continuous subcutaneous
sutures should be implemented as part of the ERAS guidelines in order
to improve patients' recovery following CD. In order to confirm our
results, a randomized-controlled trial evaluating these two surgical
techniques is currently ongoing in our department.

\textbf{Acknowledgements:}

This study was presented at the Annual Meeting of the Society for
Maternal-Fetal Medicine (SMFM), January 2020 (Poster \# 888).

\textbf{Disclosure of Interests:} The authors report no financial
interest. The authors report no conflict of
interest.\textbf{Contribution to Authorship:}Conception: RL, YZ, YG, DV
Planning: EM, RB, ZW, YG Carrying out: RL, CB, GB, NJ Analysing: RL, NJ,
YZ, DV Writing of work: RL, CB, YZ, RB\textbf{Details of Ethics
Approval:}

The study was approved by our local Research Ethics Board (0361-19-RMB),
on: December 2\textsuperscript{nd} , 2019.

\textbf{References}

1. Royal College of Obstetricians and Gynaecologists. Birth after
previous caesarean

birth: Greentop guideline no. 45. London, England: RCOG Press; 2015.

2. Betr\selectlanguage{ngerman}án AP, Ye J, Moller A, Zhang J, Gülmezoglu AM. The Increasing
Trend in

Caesarean Section Rates\selectlanguage{english} : Global, Regional and National Estimates\selectlanguage{english} :
1990-2014.

PLoS One ~2016;11(2):e0148343.

3. Martin JA, Hamilton BE, Osterman MJK, Driscoll AK. National Vital
Statistics

Reports Births\selectlanguage{english} : Final Data for 2018. NVSS 2019;68(13):1980-2018.

4. Wise J. Alarming global rise in caesarean births, figures show. BMJ.
2018 Oct 12;363:k4319.

5 . Sandall J, Tribe RM, Avery L, Mola G, Visser GHA, Homer CSE, et al.
Optimising

caesarean section use 2 Short-term and long-term effects of caesarean
section on the

health of women and children. Lancet 2018;392(10155):1349--57.

6. Carbonnel M, Brot D, Benedetti C, Kennel T, Murtada R, Revaux A, et
al. Risks

factors for wound complications after cesarean section. J Gynecol Obstet
Hum

Reprod 2020;50(7):101987.

7. Hager RME, Daltveit AK, Hofoss D, Nilsen ST, Kolaas T, Oian P, et al.

Complications of cesarean deliveries: rates and risk factors. Am J
Obstet Gynecol

2004;190(2):428--34.

8. Hammad IA, Chauhan SP, Magann EF, Abuhamad AZ. Peripartum
complications with cesarean delivery: a review of Maternal-Fetal
Medicine Units Network publications. J Matern Fetal Neonatal Med
2014;27(5):463-74.

9. Chelmow D, Rodriguez EJ, Sabatini MM. Suture Closure of Subcutaneous
Fat and

Wound Disruption After Cesarean Delivery\selectlanguage{english} : A Meta-Analysis. Obstet
Gynecol

2004;103(5):974--80.

10. Bohman VR, Gilstrap Iii LC, Ramin SM, Little BB, Santos-Ramos R,
Goldaber KG,

Dax J, Leveno KJ. Subcutaneous tissue: to suture or not to suture at
cesarean section.

Infect Dis Obstet Gynecol. 1994;1(6):259-64.

11. Anderson ER, Gates S. Techniques and materials for closure of the
abdominal wall in

caesarean section. Cochrane database Syst Rev 2004;(4):CD004663.

12. Pergialiotis V, Prodromidou A, Perrea DN, Doumouchtsis SK. The
impact of

subcutaneous tissue suturing at caesarean section on wound
complications: a meta-

analysis. BJOG 2017;124(7):1018-1025.

13. Alalfy M, Elgazzar A, Fares T, Nagy O, Ellithy A, Lasheen Y, et al.
Effect of

subcutaneous tissue closure technique in cesarean section on
postoperative wound

complications in obese Egyptian women. J Matern Neonatal Med
2019;32(15):2452--9.

14. Dahlke JD, Mendez-Figueroa H, Maggio L, Sperling JD, Chauhan SP,
Rouse DJ. The

Case for Standardizing Cesarean Delivery Technique: Seeing the Forest
for the Trees.

Obstet Gynecol 2020;136(5):972--80.

15. Caughey AB, Wood SL, Macones GA, Wrench IJ, Huang J, Norman M, et
al.

Guidelines for intraoperative care in cesarean delivery: Enhanced
Recovery After

Surgery Society Recommendations (Part 2). Am J Obstet Gynecol
2018;219(6):533--44.

16. Tuuli MG, Liu J, Stout MJ, Martin S, Cahill AG, Odibo AO, et al. A
Randomized

Trial Comparing Skin Antiseptic Agents at Cesarean Delivery. N Engl J
Med

2016;374(7):647--55.

17. Smaill FM, Grivell RM. Antibiotic prophylaxis versus no prophylaxis
for preventing

infection after cesarean section. Cochrane database Syst Rev 2014;
(10):CD007482.

18. Mackeen AD, Schuster M, Berghella V. Suture versus staples for skin
closure after cesarean: a metaanalysis. Am J Obstet Gynecol
2015;212(5):621.e1-10.

19. Schneid-Kofman N, Sheiner E, Levy A, Holcberg G. Risk factors for
wound infection following cesarean deliveries. Int J Gynaecol Obstet Off
organ Int Fed Gynaecol Obstet 2005;90(1):10-15.

20. Stone J, Bianco A, Monro J, Overybey JR, Cadet J, Choi KH, et al.
Study To Reduce

Infection Prior to Elective Cesarean Deliveries (STRIPES): a randomized
clinical trial

of chlorhexidine. Am J Obstet Gynecol 2020;223(1):113.e1-113.e11.

21. Carter EB, Temming LA, Fowler S, Eppes C, Gross G, Srinivas SK, et
al. Evidence-

based bundles and cesarean delivery surgical site infections: A
systematic review and

meta-analysis. Obstet Gynecol 2017;130(4):735--46.

22. Villers MS. Reducing Cesarean Delivery Surgical Site Complications.
Obstet Gynecol

Clin North Am 2020;47(3):429--37.

23. Chelmow D, Huang E, Strohbehn K. Closure of the subcutaneous dead
space and

wound disruption after Cesarean delivery. J Matern Neonatal Med
2002;11(6):403--8.

24. Husslein H, Gutschi M, Leipold H, Herbst C, Franz M, Worda C. Suture
closure

versus non-closure of subcutaneous fat and cosmetic outcome after
cesarean section: A

randomized controlled trial. PLoS One 2014;9(12):1--12.

25. Vermillion ST, Lamoutte C, Soper DE, Verdeja A. Wound infection
after cesarean:

effect of subcutaneous tissue thickness. Obstet Gynecol 2000;95(6 Pt
1):923--6.

26. Abbas AM. Comments on: Effect of subcutaneous tissue closure
technique in cesarean

section on postoperative wound complications in obese Egyptian women. J
Matern

neonatal Med 2019;32(21):3697.

\textbf{Table 1 - Maternal demographic characteristics}\selectlanguage{english}
\begin{longtable}[]{@{}llll@{}}
\toprule
Maternal demographic characteristics & c-STC group (n=2,459) & i-STC
group (n=3,822) & P-value\tabularnewline
\midrule
\endhead
Maternal age, years, mean \selectlanguage{ngerman}± SD & 31.4 \selectlanguage{ngerman}± 5.1 & 31.2 \selectlanguage{ngerman}± 4.8 &
0.63\tabularnewline
Gestational age at delivery, weeks, mean \selectlanguage{ngerman}± SD & 38.2 \selectlanguage{ngerman}± 0.9 & 38.3 \selectlanguage{ngerman}± 0.8
& 0.56\tabularnewline
Body Mass Index, kg/m\textsuperscript{2}, mean \selectlanguage{ngerman}± SD & 32.8 \selectlanguage{ngerman}± 2.5 & 32.6
\selectlanguage{ngerman}± 2.7 & 0.64\tabularnewline
Parity, median (range) & 2 (0-5) & 2 (0-6) & 0.81\tabularnewline
Nulliparous, n (\%) & 1,535 (62.4) & 2,362 (61.8) & 0.47\tabularnewline
Number of previous CD, median (range) & 2 (0-4) & 2 (0-4) &
0.85\tabularnewline
Gestational diabetes, n (\%) & 187 (7.6) & 275 (7.2) &
0.49\tabularnewline
Hypertension disorders*, n (\%) & 145 (5.9) & 260 (6.8) &
0.29\tabularnewline
Duration of CD, minutes, mean \selectlanguage{ngerman}± SD & 54.6 \selectlanguage{ngerman}± 11.3 & 62.5 \selectlanguage{ngerman}± 12.1 &
0.32\tabularnewline
Pelvic adhesions, n (\%) & 684 (27.8) & 1,123 (29.4) &
0.33\tabularnewline
\bottomrule
\end{longtable}

Abbreviations: c-STC, continuous subcutaneous tissue closure; i-STC,
interrupted subcutaneous tissue closure; SD, standard deviation; n,
number; CD, caesarean delivery;

*, preeclampsia or gestational hypertension

P-value \textless{} 0.05 was considered significant.

\textbf{Table 2. Outcomes of the study groups after scheduled CD}\selectlanguage{english}
\begin{longtable}[]{@{}lllll@{}}
\toprule
\begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
Outcomes of the study groups after scheduled CD\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
c-STC group (n=1,867)\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
i-STC group (n=3,121)\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
Odds Ratio (95\% Confidence Interval)\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
P-value\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
SSI rate, n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
50 (2.7)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
140 (4.5)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
1.66 (1.17-2.89)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textless{}0.0001\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Re-admission within 6 weeks for SSI, n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
22 ( 0.9) \strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
 65 (1.7) \strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
1.88 (1.23-3.21)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.002\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Maternal fever, n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
78 (3.2)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
203 (5.3)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
1.64 (1.12-2.45)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.024\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Duration of maternal fever, days, mean \selectlanguage{ngerman}± SD\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
3.2 \selectlanguage{ngerman}± 2.1\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
3.5 \selectlanguage{ngerman}± 2.4\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
1.09 (0.21-5.36)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.62\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Antibiotic use, n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
67 (2.7)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
165 (4.3)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
1.57 (1.13-2.27)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.038\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Duration of antibiotic use, days, mean \selectlanguage{ngerman}± SD\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
7.9 \selectlanguage{ngerman}± 3.3\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
7.5 \selectlanguage{ngerman}± 3.8\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
1.05 (0.33-2.48)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.56\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
CD-to-SSI time interval days, mean \selectlanguage{ngerman}± SD\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
3.1 \selectlanguage{ngerman}± 2.8\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
3.4 \selectlanguage{ngerman}± 2.9\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
1.09 (0.48-6.12)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.49\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Bacteremia and/or sepsis, n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
13 (0.5)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
28 (0.7)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
1.41 (0.66-2.37)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.33\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Post-op hospitalization duration, days, mean \selectlanguage{ngerman}± SD\selectlanguage{english}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
4.6 \selectlanguage{ngerman}± 2.3\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
4.9 \selectlanguage{ngerman}± 2.8\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
1.06 (0.31-3.34)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.55\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

Abbreviations: c-STC, continuous subcutaneous tissue closure; i-STC,
interrupted subcutaneous tissue closure; SD, standard deviation; n,
number; CD, caesarean delivery. SSI, surgical site infection

P-value \textless{} 0.05 was considered significant.

\emph{Table 3}\textbf{-Study outcomes after emergent CD}\selectlanguage{english}
\begin{longtable}[]{@{}lllll@{}}
\toprule
\begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
Outcomes of the study groups after emergent CD\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
c-STC group (n=592)\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
i-STC group (n=701)\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
Odds Ratio (95\% Confidence Interval)\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
P-value\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
SSI rate, n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
19 (3.2)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
38 (5.4)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
1.68 (1.17-2.24)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.031\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Re-admission within 6 weeks for SSI, n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
9 (1.5)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
27 (3.8)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
2.53 (1.75-3.49)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.023\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Maternal fever, n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
31 (5.2)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
68 (9.7)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
1.87 (1.26-2.41)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.035\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Duration of maternal fever, days, mean \selectlanguage{ngerman}± SD\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
3.4 \selectlanguage{ngerman}± 2.4\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
3.8 \selectlanguage{ngerman}± 2.3\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
1.11 (1.02-3.15)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.002\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Antibiotic use, n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
25 (4.2)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
48 (6.8)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
1.62 (1.21-2.27)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.044\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Duration of antibiotic use, days, mean \selectlanguage{ngerman}± SD\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
8.3 \selectlanguage{ngerman}± 3.5\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
7.9 \selectlanguage{ngerman}± 4.1\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
1.05 (0.41-3.11)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.59\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
CD-to-SSI time interval days, mean \selectlanguage{ngerman}± SD\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
2.4 \selectlanguage{ngerman}± 2.1\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
2.5 \selectlanguage{ngerman}± 2.2\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
1.04 (0.13-5.16)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.38\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Bacteremia and / or sepsis, n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
7 (1.2)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
10 (1.4)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
1.16 (0.72-1.48)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.24\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Post-op hospitalization duration, days, mean \selectlanguage{ngerman}± SD\selectlanguage{english}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
4.4 \selectlanguage{ngerman}± 2.5\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
5.3 \selectlanguage{ngerman}± 2.6\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
1.21 (0.39-4.15)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textless{}0.0001\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

Abbreviations: c-STC, continuous subcutaneous tissue closure; i-STC,
interrupted subcutaneous tissue closure; SD, standard deviation; n,
number; CD, caesarean delivery; SSI, surgical site infection

P-value \textless{} 0.05 was considered significant.

\textbf{Hosted file}

\verb`Figure 1-new.docx`  available at \url{https://authorea.com/users/737105/articles/712319-subcutaneous-tissue-closure-technique-during-cesarean-delivery-don-t-interrupt-better-continue}

\selectlanguage{english}
\FloatBarrier
\end{document}

