Steps of lscs

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Steps of LSCS (Lower Segment Caesarean Section)

The Low Transverse (Kerr) incision is the standard technique used in >90% of all caesarean deliveries. The steps below cover the complete surgical procedure from positioning to skin closure.

Pre-operative Preparation

Obtain informed consent (risks: anaesthetic complications, bladder/ureter/bowel injury, haemorrhage, infection, uterine rupture in future labour, fetal injury)
IV access, foetal monitoring, catheterisation of bladder
Prophylactic antibiotic: Cefoxitin 1 g IV (or Clindamycin 600 mg IV if penicillin-allergic) - given after cord is clamped
Antacid prophylaxis (reduces aspiration risk)

Anaesthesia

Regional (spinal or epidural) is preferred. If general anaesthesia is needed: rapid-sequence induction with cricoid pressure using Propofol 2 mg/kg (or Ketamine 1-2 mg/kg in hypovolemic patients) + Succinylcholine 1.5 mg/kg.

Positioning

Step 1 - Left lateral tilt Place a wedge under the right hip or tilt the operating table to the left. This provides left uterine displacement, improves venous return, and optimises fetal oxygenation.

Abdominal Opening

Step 2 - Pfannenstiel skin incision Incise the abdominal skin horizontally, 13-15 cm wide, two fingerbreadths above the symphysis pubis, using a no. 20 scalpel blade. Maintain haemostasis with diathermy.

Step 3 - Fascial incision Carry the incision down through subcutaneous fat to the fascia. Make a 2 cm horizontal midline incision in the fascia with the scalpel. Lift and extend the cut edges laterally and superiorly in a curvilinear fashion using curved Mayo scissors.

Step 4 - Fascial dissection Grasp the superior edge of fascia with two Kocher clamps. Bluntly dissect the fascia and linea alba away from the underlying rectus muscle using fingers, staying in the midline. Repeat on the inferior edge. Take care not to cut muscle or create a buttonhole.

Step 5 - Muscle separation & peritoneal entry Bluntly separate the rectus muscle vertically in the midline to expose the peritoneum. Grasp the peritoneum with two haemostats, tent it away from underlying structures, and incise with the scalpel. Keep the incision above the urachus to ensure it is above the bladder. Extend the incision vertically, with caution inferiorly.

Uterine Access

Step 6 - Bladder retraction Place the DeLee bladder blade to retract and identify the bladder.

Step 7 - Bladder flap development Pick up the peritoneum over the lower uterine segment with tissue forceps. Incise it laterally to create a bladder flap approximately 12 cm long. Retract the bladder inferiorly out of the operative field with the bladder blade.

Step 8 - Uterine incision (Kerr incision) Using bandage scissors, score the lower uterine segment. Create a low transverse curvilinear uterine incision through the lower uterine segment. Extend it laterally in a curvilinear fashion. Take care to avoid lateral extension into the uterine vessels.

Delivery of the Baby

Step 9 - Delivery of the fetal head Insert one hand into the uterine cavity under the fetal head. Gently flex and elevate the head through the incision. If the head is deeply impacted, an assistant applies upward pressure on the head from below vaginally (Fig. 162-13 technique). Occasionally, Terbutaline 0.25 mg SC/IV may be needed to relax the uterus (note: increases risk of uterine atony).

Step 10 - Delivery of shoulders and body Suction the infant's mouth and nose. Deliver the anterior shoulder, then the posterior shoulder, then the rest of the body - as in a vaginal delivery.

Step 11 - Cord clamping Clamp and cut the umbilical cord. Hand the infant to the attending nurse. Obtain cord blood samples if required.

Placenta and Uterine Cleaning

Step 12 - Placental delivery Manually extract the placenta bluntly with fingers. Remove any adherent membranes using ring forceps.

Step 13 - Uterine cleaning You may choose to exteriorise the uterus for better visualisation (optional). Place two Pennington clamps at the bleeding edges of the incision. Wrap the fundus in a moist lap sponge and massage. Clean the endometrial cavity with moist lap sponges to remove all clots, membranes, and debris. If the cervix is closed, dilate it with cervical dilators at this point.

Closure

Step 14 - Uterine closure Close the hysterotomy incision with a running locked stitch of 0 chromic catgut suture (single layer). If bleeding continues after single-layer closure, imbricate with a second layer.

Note: Evidence supports non-closure of the visceral and parietal peritoneum as it reduces operating time and postoperative adhesions.

Step 15 - Check haemostasis Inspect for bleeding from uterine angles, adnexa, and bladder. Irrigate the abdominal cavity. Count all sponges and instruments.

Step 16 - Fascial closure Close the rectus sheath/fascia with a continuous suture of 1-0 Vicryl.

Step 17 - Subcutaneous tissue Suturing of subcutaneous fat is generally avoided unless the layer is thick (>2 cm), as excessive suturing can increase infection risk. If needed, use interrupted absorbable sutures (3-0 chromic gut).

Step 18 - Skin closure Close skin with a skin stapler (staples placed 1 cm apart) or subcuticular absorbable sutures. A running subcuticular stitch gives the best cosmetic result.

Post-operative Care

IV oxytocin infusion: 5-10 IU/h for 4 hours to maintain uterine tone
Monitoring for haemorrhage, urine output, vital signs
VTE prophylaxis
Analgesics and early mobilisation

Types of Uterine Incisions (Summary Table)

Incision	Advantages	Disadvantages
Low Transverse (Kerr) - Standard	Thin, less vascular LUS; heals well; least risk of future rupture; >90% of cases	Risk of lateral extension into uterine vessels
Low Vertical (Kronig)	Useful when LUS is thick/fibroids; for transverse lie or fetal anomalies	Greater bladder dissection needed; may require repeat C/S if upper segment entered
Classical (vertical)	Fastest; good for emergencies; larger opening	Greater blood loss; difficult 3-layer repair; 8x higher dehiscence risk; high rupture risk in future pregnancies

- Pfenninger and Fowler's Procedures for Primary Care, 3rd Edition, Chapter 162 - Morgan and Mikhail's Clinical Anesthesiology, 7e

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