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

Indications for Lower Segment Caesarean Section (LSCS)

LSCS should be performed for specific absolute maternal, fetal, and obstetric indications that prioritize maternal and fetal survival and minimize morbidity, while recognizing that vaginal delivery remains safer for most women when no contraindications exist.

Absolute Maternal Indications

Cardiovascular Emergencies

• Severe pulmonary hypertension requires LSCS to prevent maternal decompensation and death 1, 2.
• Significant aortopathy (aortic diameter >45 mm in Marfan syndrome) mandates LSCS to prevent aortic dissection 1, 2.
• Acute maternal cardiac instability or heart failure necessitates LSCS to optimize maternal and fetal survival 1, 2.
• Maternal cardiac arrest requires delivery within 5 minutes of arrest onset through perimortem cesarean section to optimize maternal resuscitation and fetal survival 1, 2.

Anticoagulation Considerations

• Women on warfarin anticoagulation require LSCS to minimize time off anticoagulation and reduce valve thrombosis risk 1, 2.

Severe Pregnancy-Related Liver Disease

• Acute fatty liver of pregnancy (AFLP) or HELLP syndrome requires LSCS for improved maternal and perinatal outcomes 1, 2.

Airway Management

• Anticipated difficult airway mandates LSCS to avoid emergency general anesthesia complications 1, 2.

Infectious Disease Indications

HIV

• HIV-positive women with viral load >1,000 copies/mL near delivery require scheduled LSCS at 38 completed weeks of gestation, regardless of antiretroviral therapy type 1, 2.
• Intravenous zidovudine should be started at least 3 hours before the cesarean operation 1.
• The prenatal antiretroviral regimen should not be interrupted around delivery 1.

Hepatitis

• Hepatitis B does not routinely require LSCS, except in Asian HBeAg-positive women with high HBV DNA titre (>7 log₁₀ copies/ml) who have not received antiviral therapy during pregnancy 2.
• Hepatitis C with high viral load may warrant LSCS to reduce vertical transmission risk 1, 2.
• Hepatitis A does not require LSCS unless there is an obstetric indication 2.

Fetal Indications

Acute Fetal Compromise

• Immediate LSCS is required for fetal distress with irreversible causes, including major placental abruption, fetal hemorrhage, and umbilical cord prolapse with sustained bradycardia 1, 2.

Fetal Growth Restriction

• Fetal growth restriction with absent or reversed end-diastolic flow in umbilical artery warrants LSCS by 32-34 weeks 1, 2.
• Abnormal fetal surveillance, including abnormal cardiotocography or ductus venosus Doppler, requires LSCS 1, 2.

Obstetric Indications

Malpresentation

• Breech presentation requires elective LSCS at 38 weeks 2.
• Transverse fetal lie is an absolute contraindication to vaginal delivery 3.

Active Genital Infections

• Active genital herpes lesions at labor onset are an absolute contraindication to vaginal delivery 3.

Fetal Macrosomia

• Prophylactic LSCS may be considered for suspected fetal macrosomia with estimated fetal weights >5,000 g in non-diabetic women and >4,500 g in diabetic women 4.
• With estimated fetal weight >4,500 g, a prolonged second stage of labor or arrest of descent in the second stage is an indication for LSCS 4.

Previous Uterine Surgery

• The primary indications for LSCS include dystocia (37%), nonreassuring fetal heart rate (25%), abnormal fetal presentation (20%), other indications (15%), and failed operative vaginal delivery (3%) 4.

Special Circumstances

Cirrhosis with Portal Hypertension

• Vaginal delivery is preferred in women with cirrhosis, but LSCS may be required for obstetric indications 4.
• In the presence of varices, a shortened or assisted second stage reduces the need for repeated Valsalva and risk of bleeding 4.
• When LSCS is required, coagulopathy and thrombocytopenia must be corrected, and MRI/ultrasound can map intra-abdominal/pelvic varices 4.

Respiratory Disease

• LSCS should be performed for obstetric indications only in women with respiratory disease 4.
• Vaginal delivery is preferred where possible, even in high-risk respiratory cases, as it allows quicker recovery 4.

Critical Timing Considerations

• Perimortem cesarean section must be initiated approximately 4 minutes after cardiac arrest to achieve delivery within 5 minutes 2.
• No maternal survival has been reported after 15 minutes of resuscitation, and no fetal survival after 30 minutes 2.
• Elective LSCS should not be scheduled before 39 weeks unless there is a clear medical indication, as this increases neonatal respiratory complications 3.

Important Risks and Caveats

Maternal Morbidity

• LSCS carries 5-7 times higher risk of postpartum infections compared to vaginal delivery 3, 1.
• Chronic wound pain occurs in 15.4% of women at 3-6 months postpartum 1, 2.
• LSCS increases risk of placenta previa and accreta in subsequent pregnancies 1, 2.
• Uterine rupture occurs in 22 per 10,000 births in women with previous LSCS 1, 2.
• Venous thromboembolism occurs in 2.6 per 1,000 cesarean births 1, 2.
• Secondary infertility occurs in up to 43% of women after LSCS 1, 2.

Surgical Technique

• The standard approach involves a transverse lower uterine segment incision 1.
• Classical cesarean section is associated with significantly greater blood loss compared to lower segment incision in preterm deliveries 5.
• The incision should be large enough to avoid difficult abdominal delivery when macrosomia is suspected 4.

Anesthetic Considerations

• Regional anesthesia (spinal or epidural) is strongly preferred over general anesthesia for most LSCS 1, 2.
• General anesthesia can precipitate uncontrolled hypertension in women with preeclampsia and carries higher maternal risks 1.
• The 20-30° head-up position improves functional residual capacity and laryngoscopic view when general anesthesia is required 1.

Common Pitfalls to Avoid

• Performing unnecessary LSCS increases maternal risks without providing additional benefits 1.
• Inadequate preparation, including failure to have a multidisciplinary team and appropriate equipment readily available, can lead to poor outcomes 1, 2.
• Delayed decision-making in cases of true fetal distress with irreversible causes results in worse neonatal outcomes 1, 2.
• Improper disimpaction techniques during cesarean delivery can cause fetal head hyperextension, increasing risk of skull fracture and neurological injury 1.
• Overlooking maternal cardiac status can lead to poor outcomes; women with cardiac disease require careful hemodynamic monitoring during delivery 1, 2.