What are the best practices for performing a Lower Segment Caesarean Section (LSCS) on a pregnant woman, particularly one with potential underlying medical conditions such as hypertension or diabetes?

Lower Segment Caesarean Section (LSCS): Best Practices

Primary Recommendation

The transverse lower segment approach remains the gold standard for cesarean delivery, with regional anesthesia preferred over general anesthesia, and delivery reserved for obstetric indications rather than routine maternal medical conditions like controlled hypertension or diabetes. 1, 2

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Preoperative Optimization for High-Risk Patients

Patients with Hypertension

• Optimize blood pressure control preoperatively to reduce perioperative cardiovascular complications 1
• Regional anesthesia (spinal or epidural) is strongly preferred as general anesthesia can precipitate uncontrolled hypertension in preeclamptic patients 2
• Avoid general anesthesia unless absolutely necessary due to higher maternal risks 2

Patients with Diabetes

• Schedule surgery early in the day with minimal fasting to reduce risk of dehydration, acidosis, and ketosis 1
• Measure capillary blood glucose every 30 minutes during surgery if general anesthesia is used 1
• After fetal delivery, maternal insulin requirements fall rapidly—check glucose immediately if patient is on insulin 1
• Gestational diabetes patients should discontinue therapy postpartum; Type II diabetes patients can continue metformin and glibenclamide even while breastfeeding 1

Patients with Cardiac Disease

• Multidisciplinary planning with cardiology and maternal-fetal medicine is mandatory for women with hypertrophic cardiomyopathy or other cardiac conditions 1
• Regional or epidural anesthesia is reasonable, with strict precautions to avoid hypotension 1
• Cesarean section should be reserved only for obstetric reasons or emergency cardiac/maternal health reasons, as vaginal delivery has similar outcomes (3-4% adverse events) with lower bleeding rates 1

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Preoperative Preparation Protocol

Timing and Patient Preparation

• Clear liquids may be ingested up to 2 hours before surgery; light meals up to 6 hours before 3
• Consider preoperative carbohydrate drink for non-diabetic patients up to 2 hours before planned cesarean 3
• Showering with soap or antiseptic solution the night before is recommended 3
• Hair removal is not necessary; if preferred, use clipping or depilatory creams—never shaving 3
• Preoperative enema is not recommended 3

Antibiotic Prophylaxis

• Weight-based IV cefazolin 60 minutes before skin incision: 1-2g for patients without obesity; 2g for patients with obesity or weight ≥80kg 3
• Add adjunctive azithromycin 500mg IV for patients with labor or rupture of membranes 3

Hemorrhage Prevention

• Tranexamic acid (1g in 10-20mL saline or 10mg/kg IV) is recommended prophylactically for high-risk patients and can be considered for all patients 3

Thromboembolism Prophylaxis

• Routine mechanical VTE prophylaxis preoperatively, continued until patient is ambulatory 3

Pain Management

• Preoperative gabapentin can be considered to decrease postoperative pain scores with movement 3

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Intraoperative Technique

Patient Positioning

• Left lateral tilt decreases hypotensive episodes compared to right lateral tilt (which is not recommended) 3
• Manual displacers result in fewer hypotensive episodes than left lateral tilt 3
• For patients requiring general anesthesia, 20-30° head-up position improves functional residual capacity and laryngoscopic view 2

Skin and Vaginal Preparation

• Both vaginal and skin preparation with chlorhexidine (preferred) or povidone-iodine 3
• Modified Cohen's incision is the preferred skin incision technique 4

Uterine Incision

• Transverse lower segment uterine incision is the standard approach with 75 years of proven safety 2, 4
• Low vertical incision should be considered when access to lower segment is limited by prematurity, obstructing lesion, transverse lie, or high presenting part 5
• Classical (vertical corpus) incision is reserved for extreme prematurity, dense adhesions, or inability to access lower segment—but carries significant risk of uterine rupture in subsequent pregnancies (22 per 10,000 births) 6, 7

Urinary Catheterization

• Indwelling urinary catheter placement is not necessary 3
• If used, early removal (within 6-12 hours) reduces urinary tract infection risk 1

Anesthesia Management

• Regional anesthesia (spinal or epidural) is strongly preferred over general anesthesia for most cesarean sections 2, 6
• Epidural and general anesthesia are acceptable in HCM patients with precautions to avoid hypotension 1
• Maternal supplemental oxygen does not improve outcomes and is not routinely recommended 3

Placental Delivery

• Controlled cord traction after spontaneous expulsion is preferred 4

Uterine Closure

• Single-layer closure appears acceptable when technically possible 4
• Closure of visceral and parietal peritoneum is no longer necessary 4

Neonatal Care

• Delayed cord clamping for at least 1 minute at term delivery (at least 30 seconds for preterm) 1
• Maintain neonatal body temperature between 36.5°C and 37.5°C 1
• Avoid routine airway suctioning or gastric aspiration—use only for obstructive symptoms 1
• Room air is recommended for neonatal resuscitation; supplemental oxygen may be harmful 1
• Immediate neonatal resuscitation capacity is mandatory in all settings performing cesarean delivery 1

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Postoperative Care

Early Recovery

• Regular diet within 2 hours after cesarean delivery reduces thirst, hunger, improves satisfaction and ambulation, and reduces length of stay 1
• Postoperative diet should provide adequate servings of milk, fruit, vegetables, calories, and fiber to support breastfeeding and prevent constipation 1

Monitoring for High-Risk Patients

• Diabetic patients: neonates are at risk of severe hypoglycemia and require pediatric assessment 1
• Cardiac patients: hemodynamic monitoring should continue for at least 24 hours postpartum to monitor for fluid shifts 8

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Critical Safety Considerations

Surgical Safety Checklist

• A surgical safety checklist (including timeout) is recommended for all cesarean deliveries 3
• Noise levels should allow clear communication between teams 3

Common Pitfalls to Avoid

• Improper fetal disimpaction techniques can cause head hyperextension, increasing risk of skull fracture and neurological injury 6
• Inadequate uterine incisions result in fetal injury and uterine/vaginal lacerations 9
• Postpartum infections are 5-7 times more common after cesarean section compared to vaginal delivery 2, 6
• Chronic wound pain occurs in 15.4% of women at 3-6 months postpartum 6
• Cesarean section increases risk of placenta previa and accreta in subsequent pregnancies 6

Emergency Situations

• In maternal cardiac arrest, cesarean delivery must occur within 5 minutes to optimize maternal and fetal outcomes 2, 6
• No maternal survival has been reported after 15 minutes of resuscitation; no fetal survival after 30 minutes 6

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Long-Term Counseling

Future Pregnancy Considerations

• Prior classical cesarean section is contraindicated for trial of labor due to high rupture risk 7
• Uterine rupture occurs in 22 per 10,000 births after cesarean section 6
• Secondary infertility occurs in up to 43% of women after cesarean section 6
• Venous thromboembolism occurs in 2.6 per 1,000 cesarean births 6