Lower Segment Caesarean Section (LSCS)

Definition & Historical Context

Types of Uterine Incision

• Heals well
• Lower risk of rupture in subsequent pregnancies
• The uterine wound can be covered by bladder peritoneum, reducing risk of ileus, peritonitis, and adhesions
• Pfenninger & Fowler's Procedures for Primary Care, p. 1135; Creasy & Resnik, p. 964

Indications

• Fetal distress / non-reassuring CTG
• Malpresentation (breech, transverse lie)
• Very low birth weight (<1500 g)
• Fetal spinal or abdominal wall abnormalities
• Active genital herpes at onset of labour
• Cord prolapse

• Placenta previa / placenta accreta
• Cephalopelvic disproportion (CPD)
• Failure of labour to progress (dystocia)
• Previous uterine surgery / prior CS with classical incision
• Severe preeclampsia with failed induction
• Maternal HIV (for prevention of vertical transmission)

• Multiple gestation with non-vertex first twin
• Macrosomia (EFW >4500 g, or >4000 g in diabetic mother)
• Repeat caesarean
• Elective (maternal request - controversial)

Contraindications

Pre-operative Preparation

• Obtain informed consent (risks: anesthesia complications, bladder/ureter injury, bowel injury, hemorrhage, infection, hysterectomy, fetal injury, uterine rupture in future labours)
• IV antibiotic prophylaxis: cefoxitin 1 g IV (or clindamycin 600 mg if penicillin-allergic) - administered after cord clamping
• Left lateral tilt (wedge under right hip or table tilt) to avoid aortocaval compression
• Insert urinary catheter
• Regional anesthesia preferred (spinal or epidural)

Step-by-Step Surgical Technique (Low Transverse / Kerr)

1. Position: Left tilt to decompress the aorta and inferior vena cava
2. Anaesthesia: Spinal, epidural, or general
3. Skin incision: Pfannenstiel incision - ~13-15 cm, 2 fingerbreadths above the symphysis pubis, using a no. 20 blade
4. Fascia: Incise and extend laterally and superiorly in a curvilinear fashion with curved Mayo scissors
5. Rectus muscles: Separate bluntly in the midline (vertically)
6. Peritoneum: Tent with two hemostats, incise above the urachus; extend bluntly
7. Bladder retraction: Place DeLee bladder blade
8. Bladder flap: Pick up vesicouterine peritoneum, incise transversely, and bluntly dissect bladder inferiorly away from the lower uterine segment; reapply blade
9. Uterine incision: Score the lower uterine segment over the fetal head with a no. 20 blade (2-3 cm initial incision, millimeter by millimeter to avoid injuring fetal parts). Announce "uterine incision" to alert anesthesiologist and neonatologist
10. Extend incision: Bluntly with fingers, or with bandage scissors (superolaterally) - total ~10-11 cm
11. Rupture membranes: With Allis clamp (if intact)
12. Deliver fetal head: Cupped hand over occiput, wrist straight, lift upward - assistant applies gentle fundal pressure. If head is deeply impacted, assistant pushes from below vaginally
13. Deliver shoulders and body: Suction mouth and nose; deliver anterior shoulder then posterior shoulder. Clamp and cut cord
14. Deliver placenta: Manual extraction bluntly with fingers; remove membranes with ring forceps
15. Uterine closure: Running locked stitch of 0 chromic catgut (or Vicryl) - uterus may be exteriorized or closed in situ
16. Peritoneal closure: Optional
17. Fascial closure: Continuous absorbable suture
18. Skin closure: Subcuticular or staples

• Pfenninger & Fowler's Procedures for Primary Care, pp. 1136-1138

Surgical Images

Dissection of the linea alba - Fig. 162-3

Developing the bladder flap

Uterine closure - running locked stitch

Complications

Intraoperative (~2% of CS):

• Anesthesia accidents (aspiration, failed intubation, drug reactions)
• Hemorrhage
• Bladder laceration (10x more common than in operative vaginal delivery)
• Bowel injury (especially with adhesions from prior surgery)
• Amniotic fluid embolism
• Uterine extension (especially into uterine vessels)
• Scalpel laceration of fetus (rare)

Immediate postoperative:

• Atelectasis
• Endomyometritis
• Urinary tract infection
• Wound hematoma, dehiscence, infection, or necrotizing fasciitis
• Thromboembolic disease (DVT/PE)
• Paralytic ileus

Long-term:

• Repeat CS in subsequent pregnancies (>75% in the US)
• Uterine rupture in subsequent labour (0.5-1% with low transverse scar)
• Placenta previa or accreta (2-3x increased risk, rising with each CS)
• Ectopic pregnancy / scar ectopic
• Infertility (possibly from postpartum infection / tubal damage)
• Intraabdominal adhesions leading to bowel obstruction
• Creasy & Resnik, pp. 960-962

Vaginal Birth After Caesarean (VBAC)

• Non-recurrent indication for prior CS
• One prior vaginal birth
• Spontaneous labour onset
• Facility with capacity for emergency CS

Anaesthesia Considerations

• Spinal anaesthesia is the most common method - rapid onset, reliable block
• Epidural preferred when epidural already in place for labour
• CSE (combined spinal-epidural) is also used
• General anaesthesia reserved for true emergencies or when regional is contraindicated
• Key risk: maternal hypotension from sympathetic block - managed with left lateral tilt, IV fluids, vasopressors (ephedrine/phenylephrine)
• Intubation for GA carries aspiration risk (full stomach in pregnancy) - rapid sequence induction mandatory

Key Points Summary