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

Lower Segment Caesarean Section (LSCS) Steps

The optimal LSCS technique follows a standardized Enhanced Recovery After Surgery (ERAS) protocol beginning 30-60 minutes before skin incision through closure, prioritizing regional anesthesia, prophylactic antibiotics, blunt uterine expansion, two-layer hysterotomy closure, and subcuticular skin closure to minimize maternal morbidity and optimize recovery. 1

Pre-Incision Preparation (30-60 Minutes Before Surgery)

Antibiotic Prophylaxis

• Administer weight-based intravenous cefazolin 60 minutes before skin incision: 2g for patients with obesity or weight ≥80 kg, or 1-2g for patients without obesity 1, 2
• Add azithromycin 500 mg intravenous in women in labor or with ruptured membranes for additional reduction in postoperative infections 1, 3

Skin and Vaginal Preparation

• Cleanse abdominal skin with chlorhexidine-alcohol solution (preferred over aqueous povidone-iodine) 1, 3, 2
• Perform vaginal preparation with povidone-iodine solution to reduce post-cesarean infections 1, 3

Anesthesia and Patient Positioning

• Use regional anesthesia (spinal or epidural) as the preferred method 1, 3
• Add intrathecal morphine 50-100 μg or diamorphine up to 300 μg for postoperative analgesia 1
• Position patient with left lateral tilt or manual uterine displacement to prevent aortocaval compression 2

Temperature Management

• Apply forced air warming devices to prevent maternal hypothermia 1, 3
• Warm intravenous fluids and increase operating room temperature 1, 3

Surgical Steps

Abdominal Entry

• Make a Joel-Cohen incision (transverse suprapubic) for elective cases, which reduces pain and operative time 1
• Caveat: Avoid Joel-Cohen incision in confirmed placenta accreta spectrum disorder; use vertical midline incision instead for better vascular control 4
• Consider low vertical uterine incision when access to lower segment is limited by prematurity, obstructing lesion, transverse lie, or high presenting part 5

Uterine Incision

• Make transverse uterine hysterotomy at the upper part of the lower segment, approximately 2-3 cm from the vesico-uterine serosa, which reduces blood loss (188±60.1 ml vs 330.1±86.5 ml with traditional lower incision) 6
• Use blunt expansion of the transverse uterine hysterotomy to reduce surgical blood loss 1, 3

Delivery and Immediate Neonatal Care

• Deliver infant and clamp cord after at least 60 seconds for term deliveries or 30 seconds for preterm deliveries 1
• Maintain neonatal body temperature between 36.5°C and 37.5°C 1
• Avoid routine airway suctioning or gastric aspiration unless obstructive symptoms present 1

Post-Delivery Medications (After Cord Clamping)

• Administer intravenous paracetamol if not given pre-operatively 1
• Give intravenous non-steroidal anti-inflammatory drugs 1
• Administer intravenous dexamethasone for analgesia and anti-emetic prophylaxis 1
• Consider tranexamic acid 1g intravenous (or 10 mg/kg) for patients at high risk of postpartum hemorrhage 2

Uterine Closure

• Close the hysterotomy in 2 layers, which is associated with lower rates of uterine rupture and niche formation 1, 3
• Do not close the peritoneum, as closure is not associated with improved outcomes and increases operative time 1, 3

Abdominal Wall Closure

• Reapproximate subcutaneous tissue layer in women with ≥2 cm of subcutaneous tissue to reduce wound complications 1, 3
• Close skin with subcuticular suture rather than staples, which shows reduced wound separation 1, 3

Alternative Techniques for Specific Situations

• If intrathecal morphine was not administered, consider single-injection local anesthetic wound infiltration, continuous wound infusion, or fascial plane blocks (transversus abdominis plane or quadratus lumborum blocks) 1

Intraoperative Fluid Management

• Maintain perioperative and intraoperative euvolemia, which leads to improved maternal and neonatal outcomes 1, 3

Common Pitfalls to Avoid

• Do not attempt manual placental removal if placenta accreta is confirmed intraoperatively—this dramatically increases hemorrhage risk 4
• Avoid shaving hair at incision site; use clipping or depilatory creams if hair removal is necessary 2
• Do not routinely place indwelling urinary catheter; remove immediately postoperatively if placed 7
• Avoid maternal supplemental oxygen as it does not improve outcomes 2

Postoperative Immediate Care

• Continue regular paracetamol and non-steroidal anti-inflammatory drugs postoperatively 1
• Use opioids only for rescue analgesia 1
• Consider gum chewing to prevent postoperative ileus (reduces time to flatus by 7 hours) 1
• Apply abdominal binders for pain reduction 1