What are the steps of a Lower Segment Caesarean Section (LSCS)?

Steps of Lower Segment Caesarean Section (LSCS)

The surgical steps of LSCS should follow an evidence-based approach prioritizing the Joel-Cohen incision technique, blunt uterine expansion, two-layer hysterotomy closure, and selective peritoneal non-closure to optimize maternal outcomes and reduce operative time. 1

Pre-operative Preparation

Antibiotic Prophylaxis

• Administer intravenous antibiotics within 60 minutes before skin incision (not after cord clamping as previously practiced) 1
• First-generation cephalosporin is the standard choice 1
• In women in labor or with ruptured membranes, add azithromycin for additional reduction in postoperative infections 1

Skin Preparation

• Use chlorhexidine-alcohol for abdominal skin cleansing (preferred over aqueous povidone-iodine) 1
• Perform vaginal preparation with povidone-iodine solution to reduce postcesarean infections 1

Anesthesia

• Regional anesthesia (spinal or epidural) is the preferred method as part of enhanced recovery protocols 1
• Pre-operative oral paracetamol should be administered 1
• Intrathecal morphine 50-100 μg (or diamorphine up to 300 μg) provides optimal postoperative analgesia 1

Intraoperative Steps

Incision Technique

• Perform Joel-Cohen incision (Grade A recommendation for reduced pain and improved outcomes) 1
• The incision should be made transversely in the lower uterine segment 1

Uterine Entry and Delivery

• Use blunt expansion of the transverse uterine hysterotomy to reduce surgical blood loss 1
• Deliver the infant through the hysterotomy
• Delay cord clamping for at least 1 minute at term delivery (at least 30 seconds for preterm) 1

Post-Delivery Medications (After Cord Clamping)

• Administer intravenous paracetamol if not given pre-operatively 1
• Give intravenous non-steroidal anti-inflammatory drugs (NSAIDs) 1
• Administer intravenous dexamethasone for pain control and anti-emetic prophylaxis (caution in glucose intolerance) 1
• Add 10 units of oxytocin to intravenous drip for uterine contraction 2

Uterine Closure

• Close the hysterotomy in 2 layers (associated with lower rate of uterine rupture in subsequent pregnancies) 1
• Deliver the placenta and ensure hemostasis

Abdominal Closure

• Do not close the peritoneum (not associated with improved outcomes and increases operative time) 1
• In women with ≥2 cm of subcutaneous tissue, reapproximate that tissue layer 1
• Close skin with subcuticular suture in most cases (evidence shows reduced wound separation compared to staples removed at 4 days) 1

Intraoperative Considerations

Temperature Management

• Apply forced air warming, intravenous fluid warming, and increase operating room temperature to prevent hypothermia 1
• Monitor patient temperature appropriately throughout the procedure 1

Fluid Management

• Maintain perioperative and intraoperative euvolemia for improved maternal and neonatal outcomes 1

Regional Analgesia (If Intrathecal Morphine Not Used)

• Consider local anesthetic wound infiltration (single-shot or continuous infusion) 1
• Transversus abdominis plane (TAP) blocks or quadratus lumborum blocks may be used 1
• Note: These blocks provide minimal additional benefit when combined with intrathecal morphine 1

Postoperative Care

Analgesia

• Continue oral or intravenous paracetamol 1
• Continue oral or intravenous NSAIDs 1
• Opioids for rescue only when other strategies fail or are contraindicated 1
• Transcutaneous electrical nerve stimulation (TENS) may be used as adjunct 1

Supportive Measures

• Apply abdominal binders (Grade A recommendation) 1

Critical Pitfalls to Avoid

• Never delay antibiotic administration until after cord clamping - this outdated practice increases infection risk 1
• Avoid closing the peritoneum - this increases operative time without benefit 1
• Do not use staples for skin closure if they will be removed at 4 days - subcuticular sutures reduce wound complications 1
• Avoid gabapentinoids, intravenous ketamine, and neuraxial clonidine/dexmedetomidine - limited evidence and concerning side effects 1
• Do not omit basic analgesics (paracetamol and NSAIDs) when using intrathecal morphine - they work synergistically 1