Subcuticular Suture for Cesarean Skin Incision Closure

May 1, 2018 updated by: David Garry, Montefiore Medical Center

Comparison of Subcuticular Suture Type in Post-Cesarean Wound Complications

A comparison of the type of suture used for cesarean skin incision approximation and the subsequent rate of wound complications has not been widely studied. Investigators seek to compare poliglecaprone 25 and polyglactin 910 suture used in a subcuticular skin closure in Pfannenstiel incisions during cesarean birth and determine the subsequent wound complication rates (SSI, hematoma, seroma, wound separation).

Study Overview

Status

Completed

Conditions

Intervention / Treatment

Detailed Description

In the United States cesarean delivery rates in 2012 were 32.8%. The incidence of wound complications post-cesarean delivery has been quoted to be anywhere from 3-30%. Wound complications can include surgical site infection (SSI), hematoma, seroma, and wound separation. Risk factors for wound complications include elevated body mass index (BMI), prolonged duration of surgery, maternal diabetes, coexisting infection (chorioamnionitis), anemia, and increasing number of prior cesarean deliveries. The majority of cesarean deliveries are performed through a suprapubic low-transverse skin incision (Pfannenstiel incision). The incidence of wound complication post-cesarean comparing suture and staple skin closure has been extensively studied with the over all conclusion recommending suture skin closer.

A comparison of the type of suture used for skin closer and wound complication has not been widely studied. Vats et al. compared three types of suture material in post-cesarean wound complication and found statistical difference in wound discomfort, swelling and induration, wound discharge, and wound dehiscence. Their quoted wound complication rate was as high as thirty-three percent. Although, their study population was limited to emergent cesarean deliveries, the sample size was small, and their method of randomization was not explained.

Physiologic wound healing involves five steps: inflammation, granulation, epithelialization, wound contraction, and scar maturation. These biologic processes overlap in occurrence but happen in a defined order. Investigators hypothesize that suture materials with differing profiles will have different effects on these biologic processes. The two most widely used sutures for low-transverse cesarean skin incision closure in our institution are poliglecaprone 25 and polyglactin 910. Poliglecaprone 25 (monocryl) is a monofilament suture with an absorption profile of 91-119 days. Polyglactin 910 (coated vicryl) is a braided suture with an absorption profile of 56-70 days. Given the difference in profile for each suture and the physiologic wound healing process investigators question which would be more effective for wound healing.

The purpose of the study:

  1. To compare poliglecaprone 25 and polyglactin 910 suture in Pfannenstiel incision closure for prevention of wound complication (SSI, hematoma, seroma, wound separation).
  2. To determine if risk factors for wound complication should guide the choice of suture used for closure of Pfannenstiel incision.

Methods Patient enrollment will occur during their admission to labor and delivery. Patients will be approached if they meet the enrollment criteria. If they agree to participate in the trial a pre-randomized sequentially numbered, opaque, sealed envelope will be assigned to them and opened at the time of cesarean delivery which will assign the surgical suture to be used for skin closure.

Inclusion criteria for the trial:

  1. Gestational age of 37 completed weeks or greater based on their estimated due date calculated from last menstrual period or early ultrasound.
  2. Scheduled cesarean delivery or...
  3. Non-emergent cesarean delivery

Patients participating will be undergoing either:

  1. Scheduled cesarean delivery
  2. Non-emergent cesarean delivery

Non-emergent cesarean delivery will be defined as an indicated cesarean delivery based on obstetrical criteria without significant fetal heart tracing abnormalities. This would include women diagnosed with a labor dystocia or arrest of labor, failed labor induction, fetal malpresentation in labor (i.e. breech presentation) or any other non-emergent indication for cesarean delivery in which there is no immediate danger to mother or fetus.

The following exclusion criteria will be used:

  1. Urogenital tract infection within 2 weeks prior to surgery
  2. Chronic oral or injectable steroid use (> 2 weeks)
  3. Emergency cesarean delivery (need to deliver immediately due to a maternal or fetal indication)
  4. Vertical skin incision
  5. Participation in another research study

The patients will be randomized after informed consent is obtained into two groups.

Group 1: Incision closure with poliglecaprone 25 suture Group 2: Incision closure with polyglactin 910 suture

Randomization for the study will be generated using www.randomization.com, in blocks of 6 and 10 prior to the start of enrollment for the trial. Sequentially numbered, opaque, sealed envelopes will contain the surgical suture to be used for skin closure, poliglecaprone 25 or polyglactin 910.

Surgical preparation will follow departmental protocol. Once the patient is randomized to a suture group the corresponding suture will be pulled and placed on the sterile field for use after completion of the cesarean in accordance to manufacturer's guidelines. Cesarean delivery will occur following the technique of the surgeon. Maternal demographics to be obtained will include BMI, gestational age, pre and postoperative day #1 complete blood count, estimated blood loss, type of preoperative skin preparation, surgical time from skin incision to closure, birth weight, Apgar scores, newborn outcome, indication for cesarean delivery, medical history and any antenatal complications, past surgical history, postoperative course, and intraoperative or postoperative complications. Wound complication will be defined as wound separation of ≥ 1 cm in length, hematoma or seroma (serous fluid collection or subcutaneous blood collection), and surgical site infection defined by the Center for Disease Control (CDC) guidelines. The primary outcome will include a composite finding of a wound complication in the 30 day period post-operatively.

All patients will be followed until the routine postpartum visit occurs at 6-8 weeks following delivery with their primary prenatal care provider. Postpartum visit information will be extracted from the medical record. All patients will receive a follow up telephone call at post-operative day 30 or greater to monitor any post-operative complications as listed above.

An alert notification will be placed in each patient's medical record that they are enrolled in this study and close monitoring and documentation of the cesarean incision is necessary. The definition of wound complication as listed in the first paragraph above will be included in the alert notification to standardize reporting for each patient.

Recruitment Mechanisms Clinicians will ask patients during admission to labor and delivery after they meet enrollment criteria whether they are interested in the study. Consent will then be obtained by the research clinicians.

Informed Consent Patient consent will occur on admission to the labor and delivery unit. The capacity of each patient to provide ethically adequate informed consent will be assessed by the PI or his designee. It is possible that patients will be enrolled during labor prior to cesarean section if not in significant pain although the majority of patients will be presenting for scheduled cesarean sections prior to labor. Consent will be obtained from women in active labor after labor analgesia has occurred. Emergency cesareans are excluded.

Study Type

Interventional

Enrollment (Actual)

550

Phase

  • Phase 4

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Study Locations

  • United States
    • New York
      • Bronx, New York, United States, 10461
        • Montefiore Medical Center Weiler Division
      • Bronx, New York, United States, 10466
        • Montefiore Medical Center Wakefield Division

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Ages Eligible for Study

18 years to 45 years (Adult)

Accepts Healthy Volunteers

No

Genders Eligible for Study

Female

Description

Inclusion Criteria:

  • Gestational age of 37 completed weeks or greater based on their estimated due date calculated from last menstrual period or early ultrasound.

  • Patients participating will be undergoing either:

    • Scheduled cesarean delivery
    • Non-emergent cesarean delivery

Exclusion Criteria:

  • Urogenital tract infection within 2 weeks prior to surgery
  • Chronic oral or injectable steroid use (> 2 weeks)
  • Emergency cesarean delivery (need to deliver immediately due to a maternal or fetal indication)
  • Vertical skin incision
  • Active participation in another research study

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

  • Primary Purpose: Prevention
  • Allocation: Randomized
  • Interventional Model: Parallel Assignment
  • Masking: None (Open Label)

Arms and Interventions

Participant Group / Arm
Intervention / Treatment
Experimental: poliglecaprone 25 suture
Subcuticular skin approximation with poliglecaprone 25 suture at cesarean birth surgery
Device: poliglecaprone 25 suture
cesarean delivery incision closure with poliglecaprone 25 suture
Other Names:
  • MONOCRYL Suture (poliglecaprone 25 suture)
Experimental: polyglactin 910 suture
Subcuticular skin approximation with polyglactin 910 suture at cesarean birth surgery
Device: polyglactin 910 suture
cesarean delivery incision closure with polyglactin 910 suture
Other Names:
  • VICRYL Suture (polyglactin 910 suture)

What is the study measuring?

Primary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Number of Participants With Wound Complications (Surgical Site Infection (SSI), Hematoma, Separation, Seroma, Etc)
Time Frame: 30 days
Any wound disruption, fluid accumulation, separation, all CDC defined stages of surgical site infection (SSI)
30 days

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Sponsor

Montefiore Medical Center

Investigators

  • Principal Investigator: David Garry, DO, Montefiore Medical Center / Einstein College of Medicine

Publications and helpful links

The person responsible for entering information about the study voluntarily provides these publications. These may be about anything related to the study.

General Publications

Study record dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start

May 1, 2015

Primary Completion (Actual)

July 1, 2016

Study Completion (Actual)

July 1, 2016

Study Registration Dates

First Submitted

May 28, 2015

First Submitted That Met QC Criteria

May 29, 2015

First Posted (Estimate)

June 1, 2015

Study Record Updates

Last Update Posted (Actual)

June 1, 2018

Last Update Submitted That Met QC Criteria

May 1, 2018

Last Verified

May 1, 2018

More Information

Terms related to this study

Keywords

Additional Relevant MeSH Terms

Other Study ID Numbers

  • 2015-4655

This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.

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